ENHANCING YOUR SKILLS IN STROKE ENHANCING YOUR SKILLS IN STROKE QUALITY IMPROVEMENTQUALITY IMPROVEMENT

AND DATA ANALYSIS AND DATA ANALYSIS

Sherry Mosier, BSN, RN, CNRN, SCRN

Lynn Wilton, MS RN, CRRN, CNRN

DISCLOSURES

• Sherry Mosier has no actual or potential conflict of interest in relation to this presentation

• Lynn Wilton has no actual or potential conflict of interest in relation to this presentation

Methodist Hospitals, Gary/Merrillvillle• Two campus hospital system

• Methodist Hospital Northlake• Methodist Hospital Southlake

• Inpatient Beds • Total beds 634, split between the

2 campuses• Total Adult Beds 504

• Physicians • 581 Active / Associate 389

Stroke Care at Methodist Hospitals

• Each campus has been Primary Stroke Certified (PSC) by Healthcare Facilities Accreditation Program (HFAP) since 2010

• Two full time neurologists

• One neurointerventional radiologist

• One stroke coordinator• Stroke coordinator consults per month, 70 – 80

• Stroke discharges per year• 350 – 400

Parkview Health System: Allen County Campuses

Parkview Regional Medical Center Parkview Randallia

451 bed Level II Trauma Center 154 bed Community Hospital

Joint Commission Primary Stroke Center under a single license: Over 900 stroke discharges in

2014

HuntingtonLaGrange

Noble

Whitley

Parkview Health System:Community Hospitals

152 beds

Discussion Points:Quality GuidelinesThe data itselfTarget strokeReportingCore Measures

Quality

• According to the Institute of Medicine it is defined as “the extent to which health services provided to individuals and patient populations improve desired outcomes. The care should be based on the strongest clinical evidence and provided in a technically and culturally competent manner with good communication and shared decision making.”

Quality Improvement

• Key word is improvement• Analysis of performance• Systematic ways to improve it• Goal is for best outcome CHECK

Guidelines• Clinical practice guidelines are recommendations about patient care

with special conditions based on the best available research evidence and practice experience

• Stroke care quality protocols are based on:• Brain Attack Coalition• American Heart Association

• GWTG-Stroke helps facilities ensure continuous improvement of stroke treatment by aligning clinical care with evidence based guidelines

Data

• Each measure needs to be evaluated and analyzed

• Questions to ask:• Where does the information come from?• How is it coordinated?• Who is responsible?• What is done with the data?

• Analyzed according to standardized performance measures

• Review on a regular basis• Benchmark externally

“The appropriate source of data for quality assessment depends on the purpose for which the information will be used.” (NIH)

Utilize stroke database or registry (ie, GWTG or Coverdell)

Enhancing Quality Processes • Stroke Inservice/Education

• Physician and nursing educational opportunities

• Peer review• Stroke champions• Chart review• Committees

Internal and External Reporting• Internal Reporting

• Integration with hospital PI process• Leadership performance improvement• Physician performance improvement• Nursing performance improvement

• Stroke Committee• Other stroke care providers (ED, units,

EMS, non-stroke units, radiology, IR, cardiopulmonary)

• External Reporting• Quarterly submissions

• Joint Commission• HFAP• DNV• State• CMS

Core Measures• Evidence-based, scientifically-researched standard of care which has Evidence-based, scientifically-researched standard of care which has

been shown to result in improved clinical outcomes been shown to result in improved clinical outcomes • Utilizes results of evidence based medicine researchUtilizes results of evidence based medicine research• Basic core measure principles imply that it is reasonable to expect Basic core measure principles imply that it is reasonable to expect

that every patient with a given diagnosis will receive the baseline that every patient with a given diagnosis will receive the baseline (core) care established through research(core) care established through research

Importance• Appropriate Core Measure care is:Appropriate Core Measure care is:

• Right care every timeRight care every time• Reduced morbidity, mortality, complications and readmissionsReduced morbidity, mortality, complications and readmissions

• It is evidence-based best care for your patients!It is evidence-based best care for your patients!

Quality is more than just numbers, it is people working together:

Data base specialist: Diana Rupley – Activate data base, GWTGQuality specialists: Tanya Freon and Amber Schiebel Midas Quality Manager: Petra SmithSCNN coordinator: Brandy FeyNursingNeurologists/Neuro-interventionalistED physicians

HFAP SM Measure/Indicator

SM-1 Stroke Team Arrival (minutes)

SM-2 Laboratory Studies (minutes)

SM-3 Neuroimaging Studies (minutes)

SM-4 Neuro-Surgical Services (minutes)

SM-5 tPA Administration (0 - 3 hrs)

SM-6 Antithrombotic Therapy (%)

SM-7 Antithrombotic at Discharge (%)

SM-8 Anticoagulant at Discharge (%)

SM-9 DVT Prophylaxis (%)

SM-10 Statin at Discharge (%)

SM-11 Stroke Education

SM-12 Dysphagia Screening (%)

SM-13 Physical Rehab Evaluation (%)

SM-14 Door-to-Needle Time (minutes)

JC PM Measure/Indicator

STK - 1 Venous Thromboembolism (VTE) Prophylaxis

STK - 2 Discharged on Antithrombotic Therapy

STK - 3Anticoagulation Therapy for Atrial

Fibrillation/Flutter

STK - 4 Thrombolytic Therapy

STK - 5 Antithrombotic Therapy By End of Hospital Day 2

STK - 6 Discharged on Statin Medication

STK - 8 Stroke Education

STK - 10 Assessed for Rehabilitation

Target Stroke Launched 2010• A national quality

improvement initiative focused on improving acute ischemic stroke care by reducing door-to-needle times for eligible patients being treated with tPA

Target Stroke Phase II 2014: Improvement Strategies• EMS pre-notification

• Rapid triage protocol and Stroke Team notification

• Direct transfer to CT/MRI

• Single call activation system

• Rapid acquisition and interpretation of brain imaging

• Rapid laboratory testing

• Mix t-PA ahead of time• Rapid access and administration of IV

t-PA• Stroke tools:

• Stroke order set• Guidelines• Algorithms• Pathways• NIHSS• Inclusion/Exclusion

Value Based Purchasing

It Should All Start with EMS…

Role of EMS in Stroke• Primary Stroke Centers

• Primary Stroke Center recommendations by the Brain Attack Coalition in 2000 and updated in 2011 address the vital role the EMS have in the chain of survival for patients with stroke

• Primary Stroke Centers must cooperate and communicate with inbound EMS • Primary Stroke Centers are required to meet standards for EMS pre-hospital

stroke care JAMA, Volume 283, Number 23, June 21 2000Stroke 2013, Stroke, 2011, and Stroke 2007

Notification and Response of Emergency Medical Services (EMS) for Stroke• The notification and response of EMS to a stroke patient is an important part of

our process • It involves the public, the EMS systems, and the hospital EDs• Treatment for stroke is most effective if tPA is administered within three hours of

symptom onset showing decreased disability • EMS transport of stroke patients to a hospital equipped to treat strokes generally

results in better outcomes and reduced disability and death compared to patients who arrive by car or other forms of personal transport

Process Improvement for EMS

• Goals• Limit stroke disability• Improve relationship with EMS and Emergency Departments• Utilize same language for acute stroke patient throughout region

Implementation• Stroke Task Force Implemented for District 1 EMS• Committee members

• Area EMS providers• Area Stroke Coordinators

• Stroke Checklist form developed• Beta Test completed

Barriers Found

• Crews were slow to catch on/unsure of the purpose• Initially, concerns with more paperwork to complete• Where to place the completed forms• ALS vs BLS with compliance/participation

Benefits Observed• Reminders of important assessment details• Condensed form of information for radio report• Consistent reporting of “stroke” symptoms from the field• Ability to hand hospital staff information immediately

Changes Suggested

• Signatures of crew members

• FAST – check boxes – either “Normal” or “Not Normal”

Emergency Department• Core measure – STK 4, SM 5• Acute ischemic stroke patients who arrive within 120 minutes of time

last known well and for whom IV tPA was initiated at this hospital within 180 minutes of time LKW

• If patient arrives within 2 hours of onset of symptom onset, should receive thrombolytic treatment within 3 hours (FDA approved)

• May go up to 4.5 hours for treatment with consent• If ischemic stroke patient does not receive tPA within this window,

documented reason must be in the chart • Utilize tPA inclusion/exclusion criteria

ED Improvement Measures• ED Doctors and Nurses receive advanced stroke education, certified in NIHSS assessment• Standardized stroke order sets• One page notification system• Lab and CT took ownership of improvement process for TAT

• Future: Possible EMS straight to CT to decrease time to treatment

• Door to Needle time less than 60 minutes• New target stroke information, less than 45 minutes • Future: Stroke champion in the ED to review tPA patients

• Feedback on misses within one week• Feedback on tPA patients within one week

Inpatient Acute CareJC HFAP

STK - 1 SM - 1 Venous Thromboembolism (VTE) Prophylaxis

STK - 2 SM - 7 Discharged on Antithrombotic Therapy

STK - 3 SM-8 Anticoagulation Therapy for Atrial Fibrillation/Flutter

STK - 4 SM-5 Thrombolytic Therapy

STK - 5 SM-6 Antithrombotic Therapy By End of Hospital Day 2

STK - 6 SM-10 Discharged on Statin Medication

STK - 8 SM-11 Stroke Education

STK - 10 SM-13 Assessed for Rehabilitation

VTE Prophylaxis STK – 1, SM – 1 Patients with an ischemic or hemorrhagic stroke who received VTE prophylaxis or

have documentation why no VTE prophylaxis was given the day of or day after hospital admission• Improvement strategies

• Organizational policy for VTE • Meaningful use expectations• Quality measures and safety goals

• Use of stroke order sets with in the EHR• Training and education • Nursing autonomy/implementation (application of SCDS)• Documentation

Discharged on Anti-thrombotic Therapy STK – 2, SM – 7

Patients with an ischemic stroke prescribed anti-thrombotic therapy at dischargeImprovement strategies• Standardized discharge order set specific for stroke• Nursing education including stroke discharge medications

Use of e-mail tools to remind staff to monitor measures sent on a daily basis:

Patients with Afib/Flutter Receiving Anti-coagulation Therapy STK – 3, SM – 8 Patients with an ischemic stroke with afib/flutter

discharged on anticoagulation therapy

Improvement Strategies• Standardized admission and discharge order set• Admission assessment to include history of

afib/flutter or present afib/flutter• EKG monitoring per guidelines• Cardiology consult

Anti-thrombotic Therapy by End of Hospital Day 2 STK – 5, SM – 6

• Patients with ischemic stroke who receive antithrombotic therapy by the end of hospital day two (day after patient arrival)

Improvement Strategies• Standardized admission order set• Automatic best practice advisory in EMR • Education

Discharged on Statin Medication STK – 6, SM – 10Ischemic stroke patients with LDL > 100 or LDL not measured or who were

on cholesterol reducing therapy prior to hospitalization are discharged on Statin medication

Improvement Strategies• Standardized order set and discharge order set• Patient education• Contraindications• Use of hard stop in the EMR if Statin not addressed at discharge

Stroke Education STK – 8, SM – 11• Patients with ischemic or hemorrhagic stroke or their caregivers who were given educational materials

during the hospital stay addressing all of the following: risk factors for stroke, warning signs for stroke, activation of EMS, the need for follow-up after discharge, and medications prescribed at discharge

Improvement Strategies• Develop a stroke education policy

• Who – When – How • Documentation daily in the EMR• Standardize educational materials• Include patient and family in learning

expectations

Assessed for Rehabilitation STK – 10, SM – 13

Patients with an ischemic or hemorrhagic stroke who were assessed for rehabilitation services

Improvement strategies• Standard order set includes therapy

consultations• Protocol for therapy service• Follow up after discharge

References:Centers for Medicare & Medicaid (2014, August 4) CMS to Improve Quality of Care during Hospital Stays Retrieved from http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-08-04-2.html

Chang, F. (2006, February 11) Advances in Treatment of Stroke and Intracerebral Hemorrhage Power Point presentation

Cleary, P.D. and O’Kane, M.E. (n. d.) Evaluating the Quality of Health Care National Institutes of Health Retrieved from http://www.esourceresearch.org/tabid/794/Default.aspx

Filho J.O., and Koroshetz, W.J. (2014, November 26). Initial assessment and management of acute stroke retrieved from www.uptodate.com

Shekelle, P. (2014, June 5) Clinical practice guidelines http://www.uptodate.com/contents/clinical-practice-guidelines

Stroke Statements and Guidelines American Stroke Association (n.d.) Retrieved from http://my.americanheart.org/professional/StatementsGuidelines/ByTopic/TopicsQ-Z/Stroke-Statements-Guidelines_UCM_320600_Article.jsp