When Time Is Critical: How Involving Frontline Health Workers Can Improve Stroke Survival Rates

By Carmen Graffagnino,
Neurologist, Duke Hospital ; Nilima Mehta ,
Philanthropy program manager, Medtronic Foundation ; Anne Katharine Wales,
Senior philanthropy portfolio lead, Medtronic Foundation
April 09, 2019
Here are three ways to change a system of acute care.
April 10 started as an ordinary day for Sarah. But while eating breakfast, her husband noticed that her face had started to droop and she was unable to find her words. Immediately he called 911.
Within 10 minutes, the ambulance arrived with emergency medical services (EMS), a segment of the local health system that recently became partners in a new regional model for stroke care in North Carolina.
EMS quickly identified Sarah as a possible stroke victim and called the hospital to alert the stroke team to be ready for her arrival. Ten minutes later, Sarah was at the hospital and receiving scans that confirmed her stroke. Fifteen minutes later, Sarah received medication to dissolve the clot that had caused it. She was taken to the interventional radiology suite, where the neurosurgeon operated.
Survival rates shouldn’t be determined by luck.

Three hours later, Sarah woke up in the recovery room, fully alert and without any neurological deficits. She could speak and her facial drooping had resolved. Her husband breathed a sigh of incredible relief.
Sarah was one of the lucky ones.
Time is critical when dealing with a stroke and other acute events. But survival rates shouldn’t be determined by luck. The best chance for survival requires a coordinated system of care like the one Sarah experienced.
Communities need to be trained to recognize acute signs and, in the US, to call 911. 911 staff need to identify signs of a stroke and cardiac arrest to then send the appropriate EMS ambulance. EMS staff need to be trained to evaluate the patient quickly, notify the hospital, and transport the patient as quickly as possible to the hospital. And finally, hospitals need to provide timely treatment to resolve the symptoms.
Simply put, if Sarah’s husband had hesitated to call 911, she might not be alive today.
At the Medtronic Foundation, our global health work is focused on improving health outcomes for underserved populations around the world through scalable and sustainable models and interconnected systems of care. One of our core program areas is improving systems of care for acute conditions to reduce both inequities in survival and the time it takes to access care for underserved populations.
HeartRescue U.S. is a state-based initiative funded by the Medtronic Foundation that seeks to measure and improve resuscitation care, as well as build a state registry to help community-based programs improve care for sudden cardiac arrest. HeartRescue U.S. partners develop local solutions to systematically reduce barriers to resuscitation care by understanding signs and symptoms, enhance the capacity of health systems, and minimize critical time delays and disparities.
How can programs bridge the gap between hospitals and frontline EMS and community members?

Compared to other emergency health systems around the world, HeartRescue U.S. has achieved among the best results—close to 15% survival-to-hospital-discharge rates (40 million people across five states), compared to 5-10% in other national and international registries.
Building on this success in treatment of acute care emergencies, we’re also proud to partner with the Duke Clinical Research Institute on the IMPROVE Stroke Care Project, aimed at improving stroke outcomes in the Southeast U.S.
Of course, changing a system of acute care sounds like a lot of work. Will a focus like this really make a difference? How do programs like this get competitive health care systems to collaborate? And more importantly, how can programs like this bridge the gap between hospitals and frontline EMS and community members?
Here’s some of what we’ve learned through these partnerships:
Empower frontline responders as leaders and system designers.
Emergency responders are trained to evaluate the patient, triage quickly, make a hospital destination decision based on the patient condition and hospital services, and alert the right team so they are ready for the patient to arrive. Through HeartRescue U.S., we’ve found that defibrillators and thrombolytics are critical mechanisms to decreasing time to care while maximizing survival rates from sudden cardiac arrest.
Involve innovative community partnerships.
Community awareness of signs and symptoms, calling 911, and CPR training are critical, particularly for those who live in underserved areas, both urban and rural. Bystanders must call 911 without hesitation and dispatchers must be trained to recognize cardiac arrest and be equipped with telephone CPR methods. To address this, we’re seeing innovative education models at state fairs, movie theaters, barbershop screenings, social media, pamphlets in prescriptions, geographic hotspot mapping, and even proposed state legislation.
Promote a spirit of learning.
Both HeartRescue U.S. and the IMPROVE Stroke Care Projects use registry data to track performance measures and outcomes of care. Quarterly reports are shared across the regional disciplines. This framework promotes continual quality improvement where lessons and best practices can be identified with the overall goal of strengthening care delivery along all links of the chains of survival.
Transforming health care systems requires a multifaceted approach from all parties involved. Leadership and commitment from experts, local champions, and community and frontline health workers are integral to addressing disparities and building a sustainable system. This system is the reason Sarah is alive today—a mom raising three rambunctious boys.
For more on this topic, come to SwitchPoint 2019 and hear from Dr. Carmen Graffagnino of the Duke IMPROVE Stroke program, who’ll be speaking Thursday at 11:45am.
Register now for SwitchPoint 2019.