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Title: Quality Improvement In Stroke Care For Primary Stroke Center Certification at St. Francis Health Center


1
  • Quality Improvement In Stroke Care For Primary
    Stroke Center Certification at St. Francis Health
    Center
  • Washburn University
  • Masters Project by
  • Jill Collins, RN BSN
  • December 2012

2
What Is Primary Stroke Center Certification?
  • It is a program developed in 2003 by The Joint
    Commission in collaboration with The American
    Heart Association/American Stroke Association
  • Initiated in an effort to raise the bar for
    hospital stroke care
  • Recognizes centers who follow best practices for
    stroke care

3
Why Become Primary Stroke Center Certified?
  • To provide our patients with the highest quality
    stroke care in order to eliminate or
    reduce disability and return them as near as
    possible to their previous functional capacity.
  • To ensure the highest level of reimbursement for
    the quality care that we give

4
Why Address Stroke Care?Stroke Statistics
  • 3rd leading cause of death in the U.S. annually
  • Approximately 795,000 people are diagnosed with
    a
  • stroke yearly
  • 140,000 stroke related deaths occur annually
  • Many health conditions which are risk factors
    for stroke
  • are on the rise in the U.S. including obesity,
    diabetes
  • and hypertension
  • In 2010, approximately 73.7 billion was spent
    on
  • stroke-related medical costs and disability

5
What Are the Elements of Primary Stroke Center
Certification?
  • Use of a standardized method of delivering care
  • Support patient self-management activities
  • Tailor treatment and interventions to individual
    needs
  • Promote flow of patient information across
    settings and providers while maintaining HIPPA
  • Analyze and use standardized performance measure
    data to continually improve treatment plans
  • Demonstrate application of and compliance with
    clinical practice guidelines as established by
    American Heart Association/American Stroke
    Association

6
Quality and Performance Improvement
  • Very important aspect of providing the best
    quality of care
  • Requirement for Primary Stroke Center
    Certification
  • Involves continual data extraction from charts,
    input into database, analysis of data,
    recognition of areas needing improvement,
    implementing a plan of action and re-evaluation.

7
Get With the Guidelines-Stroke Registry
(GWTG-Stroke)
  • National database registry for entry of
    performance data on specified outcomes which
    include items such as those found in the stroke
    core measure set and recommended best care
    practices from the American Heart
    Association/American Stroke Association
  • Also provides information such as demographics,
    admitting diagnoses, discharge diagnoses,
    treating providers and pre-existing risk factors
    of patients
  • Allows hospitals to not only monitor their own
    performance internally but also allows for
    comparison with hospitals of similar size and
    comparison to hospitals within the state, region
    and nation
  • Was recently initiated at St. Francis Health
    Center and currently has data on over 200
    patients as part of my masters project

8
St. Francis Health Center Performance Data from
GWTG-Stroke
  • The following slides will review data collected
    from the registry in regard to performance
    at St. Francis. This shows some of the
    demographics and well as select areas of
    performance. Each performance area will have
    prior explanation as to why it was chosen to be
    included in this presentation.
  • For purposes of data graphs Baseline data is
    obtained from 30 random stroke charts from 1/1/11
    to 6/30/11, 2011 data is from all stroke charts
    from 7/1/11 to 12/31/11, current data is from
    all stroke charts from 1/1/12 to 8/31/12 and all
    hospitals is data taken from participating
    hospitals across the nation from 1/1/12 to
    8/31/12.

9
What Does Our Stroke Patient Population Look Like?
10
What Does Our Stroke Patient Population Look Like?
11
What Does Our Stroke Patient Population Look Like?
12
What Kind Of Medical Problems Do Our Stroke
Patients Have?
13
What Types of Strokes Do Our Patients Have?
14
What are Core Measure Sets?
  • A core set of recommended best practices to
    follow in regard to a given diagnosis
  • A method for The Joint Commission and Medicare to
    identify and prioritize unresolved issues
    regarding healthcare performance
  • Play an important role in establishing and
    maintaining Joint accreditation and receiving
    Medicare reimbursement
  • Current core measure sets are established for
    stroke, MI, pneumonia, CHF and surgical infection
    prophylaxis
  • Goal to be above 90 in all areas

15
Core Measure Performance at St. Francis From
GWTG-Stroke Database
  • 1. Venous thromboembolism prophylaxis (VTE).
    Documentation should be made of either having an
    ambulatory status or receiving VTE prophylaxis by
    the end of hospital day 2. This can be
    accomplished by administering subcutaneous
    unfractionated heparin, low-molecular weight
    heparins or heparinoids in patients with acute
    ischemic strokes. If there are contraindications
    to anticoagulants or the patient has had a
    hemorrhagic stroke, intermittent pneumatic
    compression devices or elastic stockings are
    recommended. Rationale patients who
    experience a stroke in which a lower extremity is
    paralyzed or paretic or who are otherwise
    non-ambulatory have increased risk of developing
    VTE or pulmonary embolism (PE). PEs account for
    10 of deaths after stroke. VTE prophylaxis has
    been shown to lower the risk of VTE and PE by
    70-80 in clinical trials (Outcome Sciences
    Inc., 2011).

16
St. Francis Data on VTE Prophylaxis
17
Core Measure Performance at St. Francis From
GWTG-Stroke Database
  • 2. Antithrombotics prescribed at discharge if
    the patient was diagnosed with non-cardioembolic
    ischemic stroke or transient ischemic attack.
    Antiplatelets rather than oral anticoagulation
    are recommended to reduce the risk of recurrent
    stroke and other cardiovascular events. Aspirin
    (50-325mg/day), Aggrenox (25/200 mg BID) or
    clopidogrel (75 mg/day) are all recommended
    therapies. Rationale substantial evidence has
    been accumulated from many large clinical trials
    which support the effectiveness of antithrombotic
    agents in reducing stroke mortality,
    stroke-related morbidity and recurrence rates.
    If the stroke is due to a cardioembolic source
    (i.e. atrial fibrillation or mechanical heart
    valve), warfarin is the preferred choice unless
    contraindicated (Outcome Sciences Inc., 2011).

18
St. Francis Data on Antithrombotics at Discharge
19
Core Measure Performance at St. Francis From
GWTG-Stroke Database
  • 3. Anticoagulation prescribed for atrial
    fib/atrial flutter. Patients with an ischemic
    stroke or transient ischemic attack who also have
    atrial fibrillation and/or atrial flutter should
    be discharged home on anticoagulation. Warfarin
    is the preferred treatment with dosages given to
    achieve an international normalized ratio (INR)
    of 2.0 to 3.0. If patients are unable to take
    anticoagulants, aspirin alone is recommended.
    Rationale non-valvular atrial fibrillation is a
    common arrhythmia and has been identified as a
    substantial risk factor for stroke. In several
    clinical trials done on patients with atrial
    fibrillation, the use of warfarin has been shown
    to decrease the relative risk of thromboembolic
    stroke by 68.

20
St. Francis Data on Anticoagulants for Atrial
Fib/Flutter
21
Core Measure Performance at St. Francis From
GWTG-Stroke Database
  • 4. IV tPA arrive by 2 hour, treat by 3 hour.
    Patients with acute ischemic stroke who arrive
    within 2 hours of the time they were last known
    to be well should have IV tPA initiated within 3
    hours of the time last known to be well. These
    patients must meet inclusion criteria as
    established by the American Heart Association.
    Rationale several clinical trials show
    favorable outcomes (defined as complete or nearly
    complete neurological recovery 3 months after a
    stroke) were achieved in 31-50 of patients
    treated with IV tPA within 3 hours of onset of
    symptoms . The major society practice guidelines
    developed in the US all recommend the use of IV
    tPA for eligible patients (Outcome Sciences Inc.,
    2011).

22
St. Francis Data on IV tPA Arrive By 2 Hours,
Treat by 3 Hours
23
Core Measure Performance at St. Francis From
GWTG-Stroke Database
  • 5. Early antithrombotics. Patients with
    ischemic stroke or transient ischemic attack
    should receive antithrombotic therapy by the end
    of hospital day 2. The recommended agents are
    the same as listed above in the antithrombotics
    at discharge section for the same rationale.
    Data suggests that antithrombotic therapy should
    be initiated within 48 hours of symptoms onset in
    order to reduce morbidity and mortality (Core
    Measure Sets Stroke, 2011).

24
St. Francis Data on Early Antithrombotics
25
Core Measure Performance at St. Francis From
GWTG-Stroke Database
  • 6. LDL 100 or not documented discharged on
    statin. Patients with ischemic stroke or
    transient ischemic attack with an LDL greater
    than or equal to 100, not measured or already on
    a cholesterol reducing agent prior to admission
    should be discharged on a statin medication
    unless there is a documented contraindication
    such as allergy. Rationale Elevated serum
    lipid levels are a well-documented risk for
    coronary artery disease and reflects an
    organ-specific manifestation of atherosclerosis
    which is a disease process that can affect the
    heart as well as major and minor branches of the
    arterial tree. Symptomatic carotid artery
    disease is one of the recognized coronary disease
    risk equivalents. The Stoke Prevention by
    Aggressive Reduction in Cholesterol Levels
    (SPARCL) study examined the effects of statins to
    lower LDL cholesterol in patients with stroke or
    transient ischemic attack of atherosclerotic
    origin who had no other reason for taking lipid
    lowering therapy and had a fasting LDL of greater
    than or equal to 100 mg/dL. This trial
    convincingly demonstrated that intensive lipid
    lowering therapy using statin medication was
    associated with a dramatic reduction in the rate
    of recurrent ischemic stroke and major coronary
    events (Core Measure Sets Stroke, 2011).

26
St. Francis Data on LDL Results and Statin
Prescription
27
Core Measure Performance at St. Francis From
GWTG-Stroke Database
  • 7. Stroke Education. Patients with stroke or
    transient ischemic attack or their caregivers
    should be given on education and/or educational
    materials during the hospital stay addressing all
    of the following personal risk factors, warning
    signs for stroke, activation of emergency medical
    system, need for follow-up after discharge and
    medications prescribed. There should be a
    specific team member identified to provide
    information to the patient and caregiver.
    Rationale many examples of how patient
    education programs for specific chronic
    conditions have increased healthy behaviors,
    improved health status and/or decreased health
    costs of their participants. Some clinical
    trials show measurable benefits in patient and
    caregiver outcomes with the application of
    education and support strategies (Outcome
    Sciences Inc., 2011).

28
St. Francis Data on Stroke Education
29
Core Measure Performance at St. Francis From
GWTG-Stroke Database
  • 8. Rehabilitation considered. All patients
    diagnosed with stroke should be assessed for
    rehabilitation services. When the patient is
    medically stable, a consult should be placed for
    rehabilitation services to assess patient
    impairments as well as activity and participation
    deficiencies to establish the patients
    rehabilitation needs and goals. It is strongly
    recommended that patients with mild to moderate
    disability in need of rehab services have access
    to a setting with coordinated and organized
    rehabilitation care team which is experienced in
    providing stroke services. Rationale of the
    795,000 patients who experience a new or
    recurrent stroke annually, about 2/3 survive and
    require rehab. A large body of evidence
    indicates better clinical outcomes when these
    patients are treated in a setting which provides
    coordinated, multidisciplinary stroke-related
    evaluation and services. These treatments can
    enhance the recovery process and minimize
    functional disability (Outcome Sciences Inc.,
    2011).

30
St. Francis Data on Rehab Assessment
31
The Golden Hour of Stroke Care
  • The benefit of IV thrombolytic therapy in
    acute brain ischemia is very much time dependent.
    Therapeutic yield is maximal in the first
    minutes after the onset of symptoms and decreases
    during the next 4.5 hours. In a typical ischemic
    stroke, for each minute reperfusion is delayed, 2
    million nerve cells die. In every 100 patients
    treated with IV thrombolytic therapy, for every
    10 minute delay in the start of lytic infusion
    within the 1 to 3 hour treatment window, 1 fewer
    patient has an improved disability outcome.
    Because of the critical importance in rapid
    treatment, national recommendations for hospitals
    that accept acute stroke patients in their
    Emergency Departments are to complete the
    clinical and imaging evaluation of the patient
    and initiate lytic therapy within 1 hour (the
    golden hour) of patient arrival. The Joint
    Commission target for primary stroke centers is
    to achieve a door-to-needle time (arrival to
    start of IV lytic therapy) of within 60 minutes
    in 80 or more of patients (Saver, et al.,
    2010). In order for patients to have IV lytics
    started, a certain sequence of events has to
    occur including evaluation by the MD, initiation
    of labwork, NIH stroke scale completed, CT scan
    of the brain done within 25 minutes and
    interpreted by a radiologist and review of
    eligibility for tPA. This also would mean that
    the goal for NIH stroke scale and door to CT lt 25
    minutes be 80 or more.

32
St. Francis Golden Hour of Stroke Care Data
33
St. Francis Golden Hour of Stroke Care Data
34
St. Francis Golden Hour of Stroke Care Data
35
Dysphagia Screening
  • Dysphagia screen one of the common
    presentations for stroke patients is difficulty
    talking and swallowing. The origin of these
    manifestations also put the patient at risk for
    aspiration. Because of this, a bedside dysphagia
    screen should be performed by a nurse and if the
    patient does not pass this, a formal swallow
    study should be done by speech therapy before the
    patient has anything by mouth including medication

36
St. Francis Data for Dysphagia Screening
37
Smoking Cessation Education
  • Smoking cessation education. Smoking is a
    common and modifiable risk factor for stroke.
    Education and assistance are key to eliminating
    this risk factor.

38
St. Francis Data on Smoking Cessation Education
39
What Areas Do We Need to Work On?
  • The following are core measure items that fall
    below the 90 goal for purposes of the
    GWTG-Stroke data
  • VTE Prophylaxis
  • Discharge on anticoags if patient has
    afib/flutter
  • Stroke Education
  • IV tPA in 3 hours if arrived by hour 2

40
What Areas Do We Need to Work On?
  • The following items currently fall below the
    suggested 80 benchmark as per The Joint
    Commission in regard to the Golden Hour of
    stroke care
  • NIHSS initially completed
  • Door to Needle less than 60 minutes
  • Door to CT lt 25 minutes
  • Final item for improvement
  • Dysphagia Screening

41
Recommendations
  • Return Stroke Coordinator position to an
    associate who solely works on improving stroke
    care and possibly other quality improvement
    projects. This person can then be responsible
    for the following which would likely improve
    scores and quality of care
  • Consistent and continual education throughout the
    facility on stroke care requirements and
    recommendations
  • Monitoring core measures as well as GWTG
    recommendations
  • Following up with patient care teams to review
    care given and make suggestions for improvement.
    This would help with accountability
  • Maintain the GWTG-Stroke database for St.
    Francis, analyze findings and implement changes
  • Work closely with the medical director of the
    stroke program to ensure policies, procedures
    and order sets are consistent with best-practice
    guidelines

42
Summary
  • In all, St. Francis Health Center really is
    doing a great job in providing quality stroke
    care. There are just a few items needing
    improvement. Most of these items are showing
    steady improvement. The items that have the
    lowest performance are still quite comparable and
    in some cases even better than hospitals
    nationwide. With additional and continual
    education and monitoring, I think these numbers
    would soon all be at goal.

43
References
  • Core Measure Sets Stroke. (2011, February 4).
    Retrieved April 25, 2012, from The Joint
    Commission
  • http//www.jointcommission.org/core_mea
    sure_sets.aspx
  • George, M. G., Tong, X., Yoon, P. W. (2011,
    February 25). Morbidity and Mortality Weekly
    Report (MMWR).
  • Retrieved January 15, 2012, from
    Centers for Disease Control
  • http//www.cdc.gov/mmwr/preview/mmwrhtm
    l/mm6007a2.htm
  • Katz, M. J. (2010). Stroke A Comprehensive
    In-Depth Review. Retrieved July 3, 2012, from
    NursingCEU.com
  • http//www.nursingceu.com/courses/301/i
    ndex_nceu.html
  • Leifer, D., Bravata, D. M., Connors III, J.,
    Hinchey, J. A., Jauch, E. C., Johnston, S. C., et
    al. (2011). Metrics for
  • Measuring Quality of Care in
    Comprehensive Stroke Centers Detailed Follow-Up
    to a Brain Attack Coalition
  • Comprehensive Stroke Center
    Recommendations A Statement for Healthcare
    Professionals From the American
  • Heart Association. Stroke Journal of
    the American Heart Association (online) , 1-29.
  • Otwell, J. L., Phillippe, H. M., Dixon, K. S.
    (2010). Efficacy and Safety of IV Alteplase
    Therapy Up to 4.5 Hours After
  • Acute Ischemic Stroke Onset. American
    Journal of Health-System Pharmacists , 1070-1074.
  • Outcome Sciences Inc. (2011). The Outcome System.
    Retrieved July 10th, 2012, from
    https//qi.outcome.com
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