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

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• 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

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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

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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

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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

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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

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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.

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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

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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.

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What Does Our Stroke Patient Population Look Like?
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What Does Our Stroke Patient Population Look Like?
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What Does Our Stroke Patient Population Look Like?
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What Kind Of Medical Problems Do Our Stroke
Patients Have?
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What Types of Strokes Do Our Patients Have?
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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

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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).

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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).

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St. Francis Data on Antithrombotics at Discharge
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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.

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St. Francis Data on Anticoagulants for Atrial
Fib/Flutter
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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).

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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).

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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).

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St. Francis Data on LDL Results and Statin
Prescription
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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).

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St. Francis Data on Stroke Education
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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).

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St. Francis Data on Rehab Assessment
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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.

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St. Francis Golden Hour of Stroke Care Data
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St. Francis Golden Hour of Stroke Care Data
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St. Francis Golden Hour of Stroke Care Data
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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

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St. Francis Data for Dysphagia Screening
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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.

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St. Francis Data on Smoking Cessation Education
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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

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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

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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

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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.

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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