Background: Mission: Lifeline is a strategic initiative to save lives and reduce disability by improving emergency readiness and response to heart attack patients. Heart disease is the number one killer in North Dakota and nationally. North Dakota consists of 53 counties over 69,001 square miles with a population of 680,000. Thirty-four entire counties are designated medically underserved areas and 13 counties have some part of them designated medically underserved. A large number of residents reside in the 36 frontier counties 21% (142,800/680,000) with a population density of < 6 people/mile, and 9 rural counties 15% (102,000 of 680,000): < 5000 residents Population density of > 6/mile together making up just over one third of the state population and 85% (45 of 53) of the physical territory. Eight urban counties with a city of at least 15,000 make up the remaining population at 63% (428,400 of 680,000). In 2011, ND M:L received a $7.1 million grant to bridge gaps in disparities in access to care by streamlining statewide STEMI systems. Methods: A statewide initiative was implemented for pre-hospital recognition, education, triage, and treatment of STEMI patients to the most appropriate reperfusion strategy. • Ninety eight percent (123 of 125) licensed ground EMS received funding to enable pre-hospital 12 lead ECG acquisition and transmission to both referral and receiving hospitals • In person facilitated education were provided to each EMS agency in 3 rounds with focus on acquisition, recognition and triaging of STEMI patients utilizing the ACC/AHA guidelines. • PCI receiving hospital physician and nurse educator teams facilitated a standardized in person clinical STEMI education session at each of the 38 referring hospitals focused on utilizing a state recommended referring hospital STEMI protocol, EMS transport guideline, and a STEMI feedback process • Six of six PCI receiving hospitals collected data utilizing the ACTION GWTG Registry Results: • In ND aggregate data from Quarter 3 2012 to Quarter 3 2013 there have been marked improvements in several measures. The ND Mission: Lifeline composite score 93% (557/ 596) to 97% (471/482) 1ST EKG obtained Pre-hospital 46% (56/122) to 76% (92/121) ED Arrival to First In-Hosp ECG % within 10 minutes 66.% (81/122) to 84% (103/122) Arrival to Primary PCI <= 90 min. from 86% (32/37) to 100% (43/43) Conclusions: To sustain STEMI system of care for patients in ND, collaboration with regional partners, care standardization, aggregate data sharing and feedback have been identified as vital. Regional champions committed to systemization are central to EMS and referral hospital engagement and state level process improvement. PCI receiving hospitals lead the way in convening regional multidisciplinary teams meetings, and facilitating data feedback on STEMI systems at a state level to support a unified platform of sustainability.
Background: Minnesota, North Dakota and South Dakota continue to build the infrastructure to improve the system of care for patients experiencing a ST-elevation myocardial infarction (STEMI). Time from symptom onset to Percutaneous Coronary Intervention (PCI) is a critical component for better patient outcomes. First responders are critical to the success of an effective STEMI system of care. However, about 52% of STEMI patients in these states are arriving by self-transport or personally owned vehicles instead of activating the system via 911. Ideally, the catheterization lab team would be notified by EMS personnel in the field or by emergency physicians after receiving the transmitted ECG indicating a STEMI and reducing the time to PCI. Methods: In time period, 774 STEMI patients were entered into ACTION Registry-GWTG from Quarter 3 2013 to Quarter 2 2014. The data included STEMI patients from 19 hospitals in Minnesota, North Dakota and South Dakota participating in Mission: Lifeline, an American Heart Association initiative to improve STEMI systems. The patients analyzed arrived directly to a PCI capable hospital. Patients transferred from a referring facility were excluded in time comparison. Arrival mode percentage comparison to first facility is the exception and includes all patients. Results: The median time from patient arrival at PCI center to catheterization lab arrival ranged between 22 and 31 minutes with a mean 26 minutes for patients arriving via EMS. Patients that came by personally owned vehicle had a median time from arrival to catheterization lab that ranged between 35 and 41 minutes with a mean of 38 minutes. The median time from hospital arrival to PCI had a mean of 42 minutes for patients arriving via EMS compared to those arriving via self-transport at 57 minutes. Conclusion: Patients arriving to a PCI hospital via EMS arrive in the catheterization lab and receive PCI faster than those arriving by personally owned vehicle. Thus, in the setting of STEMI, failure to activate EMS prolongs ischemic time.
Introduction: The American Heart Association (AHA) Mission: Lifeline Stroke program is a 3-year statewide initiative in North Dakota which aims to improve consistency of guideline-based care of stroke patients thereby improving outcomes. In year one a public awareness assessment of stroke awareness was completed. Purpose: The intent of this survey was to establish a baseline of symptom awareness related to the F.A.S.T acronym, actions and behaviors when stroke is suspected, and media preferences in ND. Methods: The AHA commissioned Marketing & Advertising Business Unlimited, Inc., to conduct a telephone survey. Four hundred phone interviews were completed with ND residents by random selection from a list of 24,000 residential landlines and 8,000 mobile phones. Numbers were stratified into five distinct regions to ensure a proper urban/rural balance. Data was also weighted by gender, age, and region to conform to the latest statewide census projects. The telephone survey had a 4.9% margin of error and a 95% confidence interval. Results: Forty seven percent of respondents stated that they had learned the signs of stroke, however only 17% classified themselves as very familiar. The most common signs identified were “Speech/Slurred Words” and “Face/Drooping Face” at 39% and 30%, respectively. In terms of F.A.S.T. awareness, 46% of survey respondents correctly identified “Face” while only 15% identified “Time.” “Arm” and “Speech” were identified 32% and 23%, respectively. Respondents indicated they would call 9-1-1 64% of the time. When asked why it may be better to be transported by personal vehicle, 74% responded you may be able to get to the hospital faster. Men and those over 65 were far less likely to correctly identify the components of F.A.S.T. Media preferences expressed were: 1) F.A.S.T. acronym over other longer options, 2) visual examples with real humans versus icons, 3) the tagline “Care Starts When You Call”, and 4) television and Facebook were the preferred mediums. Conclusions: Overall, the survey data is encouraging and may provide guidance for future rural programs. A significant portion of the respondents were deficient in stroke symptom awareness, however most survey respondents expressed interested in learning these symptoms.
The American Heart Association (AHA) Mission: Lifeline Stroke program is a 3-year initiative in North Dakota which aims to improve guideline-based care of stroke patients. Improving outcomes involves widespread awareness of stroke symptoms, early recognition, and timely access to emergency health care services. The purpose was to evaluate effectiveness of the public awareness campaign through a pre and post survey in 2018 and 2020 which assessed knowledge of the F.A.S.T acronym, actions and behaviors when stroke is suspected, and media preferences. The AHA commissioned Marketing & Advertising Business Unlimited, Inc., to conduct four hundred phone interviews in 2018 and 2020. Residents were randomly selected from a list of 24,000 landlines and 8,000 mobile phones. Data was weighted by gender, age, and region to conform to the latest statewide census. The survey had a 4.9% margin of error and a 95% confidence interval. Respondents reported having learned the signs and symptoms of stroke increased from 47.0% in 2018 to 68.3% in 2020. Awareness of symptoms changed as follows from 2018 to 2020: face related 30.0% to 43.1%; arm related 17.0% to 32.8%; speech related 39.0% to 41.0%. When asked what they would do first if stroke was suspected “Call 9-1-1- immediately” 64.0% to 70.7%, assess for F.A.S.T. symptoms then call 9-1-1 3% to 14.2%, drive themselves to the hospital 14% to 7.3% respectively in 2018 to 2020 . When asked if It would be better to transport someone experiencing stroke symptoms to a hospital by personal vehicle because driving could be faster than an ambulance in 2020 65% urban and 46% rural respondents disagreed. Media preferences were: 1) F.A.S.T. acronym over other longer options, 2) visuals with real humans 3) tagline “Care Starts When You Call”. In 2020 60% of respondents recalled advertisements about stroke signs and symptoms in the past 12 months. They recalled seeing messaging on: TV: 74.1%, Facebook: 20.1%, Radio: 19.1%, Billboard: 14.1%. Overall, the ND M:L public awareness communications were shown to have improved stroke symptom awareness and inclination to activate emergency services during a potential stroke. A preference for private vehicle presentation was noted in the rural cohort where transport time appears to be an influencing factor.
Introduction: Acute stroke care involves collaboration among multiple disciplines across the continuum of care. Interdisciplinary education consist of two or more disciplines collaborating in the learning process with the objective of promoting interprofessional coordination that improves the patient care provided by each discipline. The North Dakota Stroke System of Care (NDSSoC) Taskforce was legislatively was legislatively created in 2009 and is composed of a multidisciplinary group that collaborates to provide recommendations in the development of the North Dakota Stroke System of Care. Hypothesis: Interdisciplinary education and relationship building among hospital nursing staff and emergency medical services (EMS) staff will lead to an increase in advanced notification of stroke patients by EMS to the receiving hospital and result in an increase of stroke patients receiving a computed tomography (CT) scan within 25 minutes of arrival to hospital. Method: EMS and hospital staff is provided education at the statewide level through educational modules, regional conferences, an annual state stroke conference beginning in 2012, and at least sixteen occurrences of Primary Stroke Center stroke coordinator outreach. The NDSSoC Data was analyzed through use of the Get With the Guidelines® Patient Management Tool using 2010 as baseline data and comparing to 2015 data. Results: The percent of stroke cases with advanced notification by EMS for patients transported by EMS from scene in North Dakota increased from 56% in 2010, to 77.4% in 2015, surpassing the national average of 55.9%. Percent of patients arriving via EMS from home/scene who receive brain imaging (CT) within 25 minutes of arrival to hospitals in North Dakota increased from 23.8% in 2010 to 48.8% in 2015. Conclusion: Through providing education to EMS providers and building relationships between EMS and hospitals, there has been a significant increase in pre-notification by EMS therefore improving timeliness of CT scans in acute stroke patients.
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