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Quality at Grady

Get with the Guidelines

Improving on the exceptional quality of care is important to the physicians and staff at the Marcus Stroke and Neuroscience Center. Sharing our performance data on a regular basis is our way of demonstrating this commitment.

The information contained on this site provides data on key performance measures. We also highlight some of the many quality initiatives the health system is undertaking to further enhance and improve quality for our patients.

Stroke Quality Measures

These quality metrics are some of the requirements a hospital has to meet to become a certified stroke center. Compliance with these metrics has proven better outcomes for stroke patients based on scientific research. Click on each metric to learn more and see how Grady is doing.

STK-1: DVT Prophylaxis
Ischemic and hemorrhagic stroke patients must receive VTE prophylaxis the day of/ day after admission
Rationale: stroke patients are at an increased risk of developing a DVT as opposed to other patients. A DVT (Deep Vein Thrombosis) is a blood clot.

National Performance Goal:85%

STK-2: Antithrombotics Prescribed at Discharge
Discharged on Antithrombotic (a drug that reduces the formation of blood clots)
Rationale: data suggests patients that take daily antithrombotic after a stroke reduces morbidity and mortality.

National Performance Goal:85%

STK-3: Anticoagulation for Patients Diagnosed with A-fib or A-flutter
Patient must be discharged on anticoagulant if presents with atrial fibrillation atrial flutter
Rationale: these are risk factors for stroke. Prescribing an anticoagulant at discharge helps prevent recurrence of stroke. If patient is ineligible for anticoagulation therapy, a reason must be documented.

National Performance Goal:85%

STK-4: Initiation of IV tPA within 3 hours of “Last Seen Well” for eligible patients
tPA must be given within the applicable timeframe (if indicated)
Rationale: t-PA administration in eligible patients is most effective if used within 3 hours of symptom onset. t-PA is a medication that helps break up the clot to restore blood flow to the brain. It is the only FDA approved medication available to treat an Acute Ischemic Stroke.

National Performance Goal:85%
2013 94%
2014 94%

STK-5: Antithrombotic Therapy started by end of hospital day #2
Antithrombotics must be given by the end of Hospital day 2 or documented contraindication provided.
Rationale: studies show that administering antithrombotics within 2 days of stroke reduces morbidity and mortality.

National Performance Goal:85%
2013 97%
2014 97%

STK-6: Patients should have an LDL level drawn within 48 hours of admission. Patients with LDL >100 should be discharged home on Statin therapy.
LDL level must be drawn for all strokes within 48 hours of arrival
Rationale: Patients with LDL > 100 mg/dL should be prescribed a Statin at discharge to reduce the recurrence of stroke. High cholesterol is a risk factor for stroke.

National Performance Goal:85%
2014 100%

STK-8: Patients or family members must be provided with Stroke Education.
Stroke Education
Rationale: Patients with strokes must be educated on risk factors, activation of EMS, the importance of follow-up after discharge, medications they have been prescribed, and warning symptoms/ signs of stroke. Early activation of EMS and proper treatment of stroke significantly increases life spans of patients with stroke. Appropriate education is imperative to the reduction of morbidity and mortality.

National Performance Goal:85%
2013 97%
2014 92%

STK-10: Rehab must be considered for all patients
Patient must be assessed for Rehab Services
Rationale: two-thirds of people that suffer strokes every year survive, leaving approximately 40% with some form of functional impairment. These patients require some form of rehabilitation.

National Performance Goal:85%
2013 100%
2014 100%

Outcomes Data:

  • 53% (2014) and 59% (Q1 2015) of our stroke patients go home at discharge
  • 23% (2014) and 26% (Q1 2015) were admitted to an inpatient rehab facility

Procedure Outcomes:

  • Grady performs over 200 diagnostic brain angiographies annually with no associated complications
  • No associated complications with placing carotid arterial stents or carotid endarterectomy surgeries (2013 and 2014)

2015 Get With The Guidelines® Stroke - Gold Honor Roll Elite Plus

The American Heart Association and American Stroke Association recognize this hospital for achieving 85% or higher compliance with all Get With The Guidelines® - Stroke Achievement Measures for two or more consecutive years and achieving Time to Intravenous Thrombolytic Therapy ≤ 60 minutes in 75% or more of applicable acute ischemic stroke patients treated with IV tPA AND Time to Intravenous Thrombolytic Therapy within 45 minutes in 50% of applicable acute ischemic stroke patients treated with IV tPA to improve quality of patient care and outcomes.

Marcus Stroke Center firsts...

  • First 24/7/365 Stroke Team in Georgia - established in 1992
  • First to discover t-PA (along with 7 other US centers) as an effective treatment for acute stroke leading to FDA approval in 1996, now a standard of care in Georgia and around the US
  • First to create a statewide hospital network (Georgia Coverdell Stroke Registry) in 2001 to mentor hospitals throughout Georgia to adopt new standards of stroke care, now a network of 64 collaborating hospitals
  • First to establish a regional multi-hospital acute stroke referral network in 2010 to provide cutting edge neuroendovascular therapeutics to save brain, minimize injury and promote recovery, now with more than 70 referring hospitals
  • First angiogram suite placed in a NeuroICU in the world (2010)
  • First NeuroICU to cross train nurses to work in both ICU and angiogram suite to improve patient care and continuity
  • First to publish evidence in a major peer review journal on patient outcomes after neuroendovascular intervention for acute stroke showing that high volume comprehensive stroke centers have better patient outcomes than low volume comprehensive stroke centers
  • First to use centralized video monitoring of patients with stroke to enhance safety reducing chances for self-injury while recovering from stroke
  • First public safety-net hospital to be certified by The Joint Commission as a Primary Stroke Center in 2005, and the first to be certified as a Comprehensive Stroke Center in 2013
  • First to establish the NIH funded Georgia StrokeNet (2013) by partnering with regional hospitals to enhance and accelerate discovery of promising treatments for patients with stroke

Important Contact Info
(404) 616-1111
(404) 616-5800
(404) 616-2991
(404) 616-4282
Advice Nurse
(404) 616-0600
Pharmacy Refill
(404) 616-5500
Comprehensive Stroke Center Certification
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