ENHANCING YOUR SKILLS IN STROKE QUALITY IMPROVEMENT AND DATA ANALYSIS Sherry Mosier, BSN, RN, CNRN, SCRN Lynn Wilton, MS RN, CRRN, CNRN

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Text of ENHANCING YOUR SKILLS IN STROKE QUALITY IMPROVEMENT AND DATA ANALYSIS Sherry Mosier, BSN, RN, CNRN,...

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  • ENHANCING YOUR SKILLS IN STROKE QUALITY IMPROVEMENT AND DATA ANALYSIS Sherry Mosier, BSN, RN, CNRN, SCRN Lynn Wilton, MS RN, CRRN, CNRN
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  • 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
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  • 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
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  • 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
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  • Parkview Health System: Allen County Campuses Parkview Regional Medical Center Parkview Randallia 451 bed Level II Trauma Center154 bed Community Hospital
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  • Joint Commission Primary Stroke Center under a single license: Over 900 stroke discharges in 2014
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  • Huntington LaGrange Noble Whitley Parkview Health System: Community Hospitals 152 beds
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  • Discussion Points: Quality Guidelines The data itself Target stroke Reporting Core Measures
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  • 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.
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  • Quality Improvement Key word is improvement Analysis of performance Systematic ways to improve it Goal is for best outcome CHECK
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  • 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
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  • 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)
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  • Enhancing Quality Processes Stroke Inservice/Education Physician and nursing educational opportunities Peer review Stroke champions Chart review Committees
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  • 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
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  • Core Measures Evidence-based, scientifically-researched standard of care which has been shown to result in improved clinical outcomes Evidence-based, scientifically-researched standard of care which has been shown to result in improved clinical outcomes Utilizes results of evidence based medicine research Utilizes results of evidence based medicine research Basic core measure principles imply that it is reasonable to expect that every patient with a given diagnosis will receive the baseline (core) care established through research Basic core measure principles imply that it is reasonable to expect that every patient with a given diagnosis will receive the baseline (core) care established through research
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  • Importance Appropriate Core Measure care is: Appropriate Core Measure care is: Right care every time Right care every time Reduced morbidity, mortality, complications and readmissions Reduced morbidity, mortality, complications and readmissions It is evidence-based best care for your patients! It is evidence-based best care for your patients!
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  • Quality is more than just numbers, it is people working together : Data base specialist: Diana Rupley Activate data base, GWTG Quality specialists: Tanya Freon and Amber Schiebel Midas Quality Manager: Petra Smith SCNN coordinator: Brandy Fey Nursing Neurologists/Neuro-interventionalist ED physicians
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  • HFAP SMMeasure/Indicator SM-1Stroke Team Arrival (minutes) SM-2Laboratory Studies (minutes) SM-3Neuroimaging Studies (minutes) SM-4Neuro-Surgical Services (minutes) SM-5tPA Administration (0 - 3 hrs) SM-6Antithrombotic Therapy (%) SM-7Antithrombotic at Discharge (%) SM-8Anticoagulant at Discharge (%) SM-9DVT Prophylaxis (%) SM-10Statin at Discharge (%) SM-11Stroke Education SM-12Dysphagia Screening (%) SM-13Physical Rehab Evaluation (%) SM-14Door-to-Needle Time (minutes) JC PM Measure/Indicator STK - 1Venous Thromboembolism (VTE) Prophylaxis STK - 2Discharged on Antithrombotic Therapy STK - 3 Anticoagulation Therapy for Atrial Fibrillation/Flutter STK - 4Thrombolytic Therapy STK - 5Antithrombotic Therapy By End of Hospital Day 2 STK - 6Discharged on Statin Medication STK - 8Stroke Education STK - 10Assessed for Rehabilitation
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  • 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
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  • 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
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  • Value Based Purchasing
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  • It Should All Start with EMS
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  • 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 2000 Stroke 2013, Stroke, 2011, and Stroke 2007
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  • 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
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  • Process Improvement for EMS Goals Limit stroke disability Improve relationship with EMS and Emergency Departments Utilize same language for acute stroke patient throughout region
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  • Implementation Stroke Task Force Implemented for District 1 EMS Committee members Area EMS providers Area Stroke Coordinators Stroke Checklist form developed Beta Test completed
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  • 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
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  • 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
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  • Changes Suggested Signatures of crew members FAST check boxes either Normal or Not Normal
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  • 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
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