332

Journal of Neuroscience Nursing

Improving Stroke Education Performance

Measures Scores: The Impact of a Stroke
Nurse Coordinator
Josephine Malfitano, Barbara S. Turner, Ed Piper, Penney A. Burlingame,
Elizabeth DAngelo

ABSTRACT
Background: Stroke is a leading cause of death and adult disability worldwide. North Carolina is
considered to be a part of an area of the United States called the stroke belt. Education coupled with
implementation of a program that promotes primary and secondary stroke prevention is paramount to
support the reduction of stroke and improvement of stroke care across the continuum. The groundwork for
stroke care at Onslow Memorial Hospital began in 2006 with participation in the North Carolina Stroke
Care Collaborative (NCSCC), which allowed for benchmarking of data. Methods: A pretest and posttest
design was used to evaluate the effectiveness of a dedicated stroke nurse coordinator on stroke education
performance measure scores. Compliance with stroke education performance measures is met when
documentation reflects education provided or material given during the hospital stay. Three hundred sixty-seven
charts submitted to the NCSCC from Onslow Memorial Hospital were reviewed. Data collected were entered
into the NCSCC Registry database during the period of 2008Y2010. Performance measures were compared at
three points: the year before implementation of the stroke nurse coordinator, the implementation year, and,
the year after the implementation of the stroke nurse coordinator position. Results: Stroke education
performance measure scores for the preimplementation year (2008) were 58.1%, which improved to 86.4%
for the year that the nurse coordinator position was created and filled, and rose to 96.9% for the 1-year
period after the position was filled. Scores from Z tests comparing proportions over time between each of the
3 years were statistically significant. Conclusions: Implementation of a stroke nurse coordinator to improve
stroke care and education is a coordinated effort that will impact stroke outcomes across the healthcare
continuum, with efforts geared toward primary and secondary prevention strategies. This role provides
supportive resources for the community, individualized care with patients and families as well as supporting
staff in providing stroke education, and awareness. Stroke education has shown improvement in patients
understanding the signs and symptoms of stroke as well as improved compliance with treatment plans; the use
of a dedicated educator is supported.
Keywords: education, nurse coordinator, performance measures, quality, stroke, stroke education

troke is a leading cause of death and adult disability worldwide and the fourth leading cause
of death in the United States. North Carolina

Questions or comments about this article may be directed to

Josephine Malfitano, DNP MBA RN FNP CPHQ NE-BC, at jo.malfitano@
onslow.org. She is the Performance Improvement & Accreditation
Manager, Onslow Memorial Hospital, Jacksonville, NC.
Barbara S. Turner, PhD RN FAAN, is the Elisabeth P. Hanes
Distinguished Professor and Director of the Doctor of Nursing Practice
Program at Duke University School of Nursing, Durham NC.
Ed Piper, PhD FACHE, is the President and CEO of Onslow Memorial
Hospital, Jacksonville, NC.
Penney A. Burlingame, DHA RN FACHE, is the Senior Vice President
of Nursing and Clinical Services of Onslow Memorial Hospital,
Jacksonville, NC.
Elizabeth DAngelo, MD, is a Radiologist and Chief of Staff at
Onslow Memorial Hospital, Jacksonville, NC.
The authors declare no conflicts of interest.
Copyright B 2013 American Association of Neuroscience Nurses
DOI: 10.1097/JNN.0b013e3182a3ce63

ranks fifth in the nation in the incidence of strokes

(American Heart Association, 2011; Huston, 2010;
North Carolina Stroke Care Collaborative [NCSCC],
2010) and is a part of the southeastern United States
called the stroke beltVa cluster of 8Y12 states
with higher stroke mortality than the national average
(NCSCC, 2010). In addition to the human suffering
caused by strokes, the economic impact of strokes in
North Carolina is estimated at 1.05 billion dollars a
year (Holmes, 2008).
Currently, only 18% of adults in North Carolina
can correctly identify stroke signs and symptoms, and
those at high risk for stroke with (hypertension or a
previous stroke) do not know the symptoms any better
than those at lower risk (Holmes, 2008). Educating
the public as well as those who have experienced
stroke, their families, and healthcare professionals on
the signs and symptoms and need for early intervention is one strategy for improving stroke prevention
and outcomes. A focused resource provider who offers

Copyright 2013 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

Volume 45

stroke education to patients, families, and staff is a

means to support one of the stroke quality indicators
proposed by the NCSCC and The Joint Commission.

Background
A lack of prevention strategies and lack of care coordination once stroke patients leave the hospital are
major problems in stroke care (Lennert, 2009). Given
the importance of early intervention for stroke, it is
imperative that patients and families understand risk
factors for stroke, recognize stroke signs and symptoms, and act by calling 9-1-1. Research suggests that
delay in seeking treatment for acute coronary and
stroke symptoms limits effective treatment options
and results in a greater likelihood of permanent disability or death (Huston, 2010). Redfern, Rudd, Wolfe,
and McKevitt (2008) have reported on attempts to improve secondary prevention of stroke through patient
and caregiver education initiatives to improve stroke
knowledge. One approach described was the development of nurse coordinators to transition the patients
care between healthcare providers, with the goal of
improving access to care. Lindsay et al. (2008) found
that stroke education improved patient knowledge of
signs and symptoms of stroke as well as compliance
with the treatment plans for stroke. Similarly, Green
and Newcommon (2006) have reported that implementation of stroke standards of care along with a dedicated stroke educator improved the quality of care for
stroke patients after discharge and also improved systems and processes.
These studies point to the need for focused education interventions to improve stroke care and outcomes.
Yet, despite awareness among health professionals of
the importance of risk factor management for secondary stroke prevention, studies show that adherence
to secondary prevention is still poor (Slark, 2010).
Strategies are needed to involve patients and families
in sharing information, setting goals, and assessing
needs, which are a part of discharge planning (Almborg,
Ulander, Thulin, & Berg, 2009). Understanding the
needs of stroke patients and their families can provide
a basis for educational processes to improve outcomes.

Setting and Methods

In North Carolina, Onslow County is in the southeastern region of the state, a significant risk area for
stroke; it is considered the buckle of the stroke belt,
an area with even greater stroke mortality, three times
higher than the national average (NCSCC, 2010). The
region has high rates of hypertension, cardiovascular
disease, obesity, and diabetesVfactors that put the population at significant risk for stoke according to the

&

Number 6

&

December 2013

Because prevention and early

recognition of stroke are critical in
minimizing the potentially negative
short- and long-term outcomes
related to cerebrovascular disease,
it is imperative that patients and
families receive focused education
that could improve these.

NC County Trends report from the NC Department of

Health and Human Services. Onslow County showed
an increase in stroke deaths in 2006, despite a decline
in overall state deaths from stroke (North Carolina Department of Health and Human Services Resources:
Division of Public Health, 2006).
Onslow Memorial Hospital (OMH) is a 162-bed
not-for-profit acute-care community hospital. OMH is
a leader in healthcare to a community that has significant uninsured and underserved populations. These
populations regularly seek acute disease management
through the emergency department because they have
limited access to primary care, and they receive inconsistent follow-up for prevention of recurrent strokes.
OMH began in 2006 through participation in the
NCSCC, benchmarking data. Initial data collected that
year showed that compliance in providing stroke
education was only 28%. There was a clear need to
improve stroke care at OMH. Improvements in stroke
care were made by implementing standing orders,
using evidence-based clinical practice guidelines for
inpatients and the emergency department, improving
dysphagia screening, and the process of expediting
radiology diagnostic testing and developing a stroke
folder with patient education material. Compliance in
stroke education improved to 40% in 2007. However,
the stroke team believed that more could be accomplished with the implementation of a full-time stroke
nurse coordinator (SNC) to provide stroke education/
awareness and prevention strategies to frontline staff,
patients, and families.
OMHs focus is on increasing the states stroke
awareness program using a three-pronged approach:
prevention and education in prehospital screening,

Copyright 2013 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

333

334

Journal of Neuroscience Nursing

individualized acute care education, and posthospital

follow-up. The dedicated educator/SNC serves as the
liaison and resource for community stroke needs and
patient and family education, while also providing
education and support to hospital staff. The SNC also
facilitates interdisciplinary care coordination and monitors stroke outcomes.
The SNC provides community outreach and education on inpatient and poststroke care by leveraging
NC Stroke Association Programs and by implementing
established standards of stroke care. A Stroke Risk
Identification Screening Program provides standardized protocols for identifying stroke risk factors, counseling participants, directing them to resources, and
providing outcome management through partnerships
for those found to be at high risk for stroke. In this
way, we identify interventions needed or potential
problems with access. A Beyond the Hospital Program
provides evidence-based practice protocols for poststroke education to patients in the acute care setting
and at discharge. Each person is then contacted within
3 months with a follow-up call. This approach provides

TABLE 1.

quantifiable care measures and educational outcomes

for stroke prevention.
The SNC serves as a center for education and facilitation of stroke care across the continuum. The work
begins with programs to increase community awareness and healthcare screenings as well as interactions
with the local health department and emergency management offices to establish collaborations in stroke care.
In the hospital, the stroke nurse makes rounds daily to
reinforce inpatient stroke care based on evidence-based
guidelines. Patients and families are provided educational materials, video-on-demand stroke resources, and
an interdisciplinary plan of care based on individual
needs. The SNC ensures that staff education is ongoing
from the time of orientation to the organization; the education includes annual mandatory computerized module
learning, regular staff meetings, and real-time feedback
with chart reviews and updated care management discussions. The SNC is readily accessible to staff via
pager and also supports families. The coordinator also
reviews cases, analyzes and shares data for stroke improvement initiatives, and serves as a resource for other

Demographics by Years 2008Y2010

N (%) by Year

Variables

Overall, n (%)

Year 2008

Year 2009

Year 2010

(N = 418)

n = 126 (%)

n = 143 (%)

n = 149 (%)

18 (4.3)

7 (5.6)

5 (3.5)

6 (4.0)

Age in groups, years

18Y44
45Y64

150 (35.9)

50 (39.7)

45 (31.5)

55 (36.9)

65Y74

102 (24.4)

33 (26.2)

42 (29.4)

27 (18.1)

75+

148 (35.4)

36 (28.6)

51 (35.7)

61 (40.9)

Male

187 (44.7)

61 (48.4)

51 (35.7)

75 (50.3)

Female

231 (55.3)

65 (51.6)

92 (64.3)

74 (49.7)

White

300 (71.8)

88 (69.8)

99 (69.2)

113 (75.8)

Black

108 (25.8)

32 (25.4)

42 (29.4)

34 (22.8)

Others

10 (2.4)

6 (4.8)

2 (1.4)

2 (1.3)

12 (2.9)

2 (1.6)

4 (2.8)

6 (4.0)

Non-Hispanic White

288 (68.9)

86 (68.3)

95 (66.4)

107 (71.8)

Non-Hispanic Black

108 (25.8)

32 (25.4)

42 (29.4)

34 (22.8)

10 (2.4)

6 (4.8)

2 (1.4)

2 (1.3)

283 (67.7)

78 (61.9)

106 (74.1)

99 (66.4)

Private

40 (9.6)

5 (4.0)

6 (4.2)

29 (19.5)

No insurance

29 (6.9)

5 (4.0)

4 (2.8)

20 (13.4)

Not documented

66 (15.8)

38 (30.2)

27 (18.9)

1 (0.7)

Gender

Race

Race and ethnicity

Hispanic White

Others
Health insurance
Medicare/Medicaid

Copyright 2013 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

Volume 45

&

Number 6

&

December 2013

TABLE 2. Stroke Education Compliance Scores Z Test Comparison Proportions Over Time
Sample Population:
Stroke Only

Sample Population:
Stroke and TIA

Comparing Proportions
Over Time:
Probability by Year

Sample Population:
Stroke Only

Year

Performance
Measure Score

Performance
Measure Score

Year

Z Score

2008

62

58.1

108

49.1

2008Y2009

3.716

.0001

2009

66

86.4

120

80.0

2009Y2010

2.2003

.0139

2010

65

96.9

104

91.3

2008Y2010

5.8097

G.0001

2011a

21

95.2

35

97.1

Note. Data provided by NCSCC.

a
Statistically significant at p G .05.

facilities to network, benchmark data, and develop best

practices measures in stroke care.
Key supporters of the role of the SNC are stroke
champions, including those in frontline nursing, rehabilitation, radiology, pharmacy, dietary, education, local
Emergency Medical Services, emergency department
staff/providers, and leadership. The SNC facilitates
the work of interdisciplinary teams so that stroke care
and education are consistent across the continuum.
Evidence-based practice guideline protocols and policies
as well as tools and checklists for more effective and
efficient documentation have been developed. Hardwiring system improvements and processes include
checklist documentation on the nursing record and
interdisciplinary discharge plans of care. Local newspaper
articles have been developed on stroke awareness, along
with Web sites and videos. Additional educational resources include a stroke awareness packet, stroke risk
pamphlet, and stroke publication flyers provided to
patients and staff.
Stroke education is one of 10 quality performance
indicators endorsed by the National Quality Forum. The
stroke education performance measures state that meeting compliance in stroke education requires that documentation of ischemic stroke patients or their caregivers

were given educational material during their hospital stay

addressing all of the following five elements: activation
of the emergency medical system, follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of
stroke (The Joint Commission and Center of Medicare/
Medicaid Services, 2011).
Accurate and consistent documentation of education
must be recorded in the medical record. When documentation is incomplete, the performance is considered
a failure or variance.
To determine whether an SNC improved stroke
education, we collected data at three measurement
points to see if there were significant trends in stroke
education performance scores: 2008, the year before
introduction of the SNC; 2009, the year of implementation; and 2010, the year after implementation of
the SNC position. The first 6 months of 2011 were
also analyzed to determine if improvements were sustained. During 2008Y2011, 418 stroke patient charts
were reviewed. To be included in the analysis, patients
had to be 18 years old or older and discharged with an
ICD-9 for stroke. Patients who had a length of stay
greater than 120 days, palliative care patients, and patients
enrolled in clinical trials or patients admitted for elective

FIGURE 1 Stroke Education Performance Measure Scores by Year: Stroke Patients Only

Copyright 2013 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

335

336

Journal of Neuroscience Nursing

FIGURE 2 Stroke Education Performance Measure Scores by Year: Ischemic Stroke and
TIA Patients

carotid intervention were excluded. Using these inclusion criteria, there were 367 charts eligible for review.
The NCSCC conducts a data quality assessment
annually. Reliability of 5% of the data entered into the
NCSCC Registry from April 2009 through June 2010
was examined to determine if the data submitted to
the NCSCC were in agreement with the medical record documentation. There was 95% congruence in
data elements. Additional quality assessment was conducted through case ascertainment to determine if the
number of stroke cases admitted to the hospital during
a designated 60-day period was consistent with the
number of missing cases entered and to determine if
the number and type of stroke cases admitted to the
hospital during a 1-year period was comparable with
those entered into the NCSCC.
Data abstraction followed consistent and recognized national guidelines. Data for obtaining stroke
education performance measures were collected using
retrospective chart audits following the format of the
NCSCC stroke care cards, which contain numerous
questions to determine if documentation to support
compliance with performance indicators is maintained.
Charts were selected for review using patients who
were discharged with an ICD-9 stroke code. The sample included 100% of the stroke patients who were

hospitalized in the preimplementation and postimplementation times. Charts were reviewed monthly,
and data abstraction was done by the SNC and three
performance improvement personnel, who were trained
to abstract data and follow the prescribed definitions
to enter the data into the appropriate databases. Assigning consistent staff for data abstractions prevented variability in the interpretation of the data. To further support
the reliability and integrity of the data, queries related
to stroke performance measures that were identified during chart abstraction were filtered through the NCSCC
Registry or the Joint Commission for clarification.

Data Analysis
Three hundred sixty-seven patient records from 2008
to 2011, including 35 chart audits during JanuaryY
June 2011, were analyzed. All included inpatients with
a primary diagnosis of ischemic stroke and/or transient
ischemic attack who met the inclusion criteria.
Table 1 depicts the demographic of the sample, and
Table 2 and Figures 1Y3 document improvement in stroke
education compliance scores, from 58.1% in the year
before the initiation of the SNC role to 86.4% in the
year the role was filled and 96.9% in the year after the
role was initiated. Data for 2011 (partial year) showed
continued sustainability of the improvement, at 95.2%.

FIGURE 3 Stroke Education Performance Measures Scores by Year: Ischemic Stroke

and/or TIA Patients Comparing Onslow Memorial Hospital and North
Carolina Stroke Care Collaborative

Copyright 2013 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

Volume 45

When the data from patients with stroke and transient ischemic attack were analyzed, the improvements
in stroke education compliance scores were similar to
those for stroke alone.

Discussion
Implementation of the SNC role was associated with
improved stroke education performance measure scores.
The coordinator provides supportive resources for the
community and individualized care for patients and
families, while also supporting staff in providing stroke
education and awareness. The SNC functions to align
collaborative stroke care efforts for seamless process
improvement in the acute care setting. Studies of compliance in poststroke care management at home have
shown that adherence to secondary prevention is still
poor, supporting the significance of this role for stroke
education and awareness among healthcare professionals, patients, and families (Slark, 2010). Stroke
healthcare teams need to develop strategies to involve
relatives of stroke patients in sharing information,
goal setting, and discharge planning (Almborg et al.,
2009). Understanding the needs of stroke patients
and their families can assist the care team to provide
education for improved outcomes. Additional considerations include further investigations that will
align the compliance with performance measures and
outcomes notable with strategies currently being
implemented such as with postdischarge telephone
calls and demonstration of readmission reduction.
Since the implementation of the SNC role at OMH,
stroke education compliance has shown sustained
improvements, from 58% in 2008, the year before
implementation of the coordinator, to 86% in 2009
(the implementation year) and 96% at the end of
2010 (1-year post implementation of the SNC role).
In the first 6 months of 2011, the data continue to show
sustainability, with stroke education performance
scores at 95%.
Of interest is that the data from OMH, when compared with North Carolina statewide scores, show higher
performance measures for 2009Y2011Vthe time period associated with the use of the dedicated SNC.
The best way to treat a stroke is to prevent it (Albert,
2011). Education is the mechanism for delivering this
messageVprimary prevention and, in the case of the
population involved in the study, secondary prevention. Patients who have had a stroke are at higher risk
for another stroke. Education coupled with implementation of a program that promotes primary and/or
secondary stroke prevention is paramount to support
the reduction of stroke and improvement of stroke care
across the continuum. Strategies that enhance patient
and professional awareness of stroke risk factors are

&

Number 6

&

December 2013

feasible to produce and deliver and can improve stroke

care and disease management (Lennert, 2009). The
SNC role supports stroke care improvement interventions and strategies for increasing education and awareness of risk factors, medications, signs, and symptoms
of stroke and activation of emergency management
system calling 9-1-1.

Acknowledgments
This project was funded in part through the North
Carolina Stroke Care Collaborative, North Carolina
Stroke Association, and Kate B. Charitable Trust.
Data were provided through the North Carolina
Stroke Care Collaborative.

References
Albert, M. (2011). Personal communication. Northwestern University. m-alberts@northwestern.edu
Almborg, A., Ulander, K., Thulin, A., & Berg, S. (2009).
Review: Understanding the needs of families: Discharge
planning of stroke patients: The relatives perceptions of
participation. Journal of Clinical Nursing, 18, 857Y865.
American Heart Association. (2011). About stroke. Retrieved
http://www.strokeassociation.org/STROKEORG/AboutStroke/
AboutStroke_UCM_30829_SubHomePage.jsp
Green, T., & Newcommon, N. (2006). Advanced nursing practice:
The role of the nurse practitioner in an acute stroke program.
Journal of Neuroscience Nursing, 38(4), 328Y330.
Holmes, A. (2008). Stroke in North Carolina: Addressing the burden
together. Raleigh, NC: NC Stroke Advisory Council Meeting.
Huston, S. (2010). Heart disease and stroke prevention branch
chronic disease and injury section: The burden of cardiovascular disease in North Carolina (annual report). Division
of Public Health, North Carolina Department of Health &
Human Service. Retrieved from http://www.startwithyourheart
.com/Default.aspx?pn=CVDBurden
Lennert, B. (2009). Care management for TIA and stroke
patients: Riding the quality improvement wave. American
Health and Drug Benefits, 2(6, Suppl. 8), S24YS27.
Lindsay, P., Bayley, M., Hellings, C., Hill, M., Woodbury, E.,
& Phillips, S. (2008). Public awareness and patient
education: Patient and family education. Canadian Medical
Association Journal, 179(Suppl. 12), 15Y16.
North Carolina Department of Health and Human Services Resources: Division of Public Health. (2006). North Carolina
Statewide and County Trends in key health indicators: Onslow
County. Raliegh, NC: State Center of Health Statistics.
North Carolina Stroke Care Collaborative. (2010). North
Carolina in the buckle of the stroke belt. Retrieved http://
ncstrokeregistry.com/stroke2010/Overview/Stkbuckle.htm
Redfern, J., Rudd, A., Wolfe, C., & McKevitt, C. (2008). Stop
stroke: Development of an innovative intervention to
improve risk factor management after stroke. Patient
Education and Counseling, 72, 201Y209.
Slark, J. (2010). Adherence to secondary prevention strategies
after stroke: A Review of the literature. British Journal of
Neuroscience Nursing, 6(6), 282Y286.
The Joint Commission and Center of Medicare/Medicaid
Services. (2011). Specifications Manual for National
Hospital Inpatient Quality Measures (Version 3.2c) [data
file]. Washington, DC: Author.

Copyright 2013 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

337