Stroke Special Project 640 and 740Resource For Health Information Management Professionals

Linda Gould RPN

Erin Kelleher, BA, CHIM

Stefan Pagliuso PT, B.A. Kin(Hon.)

Overview of this Resource

• Overview of Organized Stroke Care

• Review purpose of Special Projects for stroke care

• Clinical use

• Performance monitoring use

• Review projects 640 , 740

• Overview from Clinical Perspective

• Tips

Stroke In Canada

• Someone has a stroke every 9 minutes

• 62,000 strokes occur in Canada every year

• More than 400,000 Canadian are living with long-term stroke disability

• Increase in strokes among people under 65

http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483991/k.34A8/Statistic

s.htm

Stroke Impact

• For every minute delay in treating a stroke, the average patient loses 1.9 million brain cells

• Depression following a stroke and changes to cognition affect up to 30-60% of stroke survivors within the first year – this is associated with impaired recovery as well as decreased function in activities of daily living

http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483991/k.34A8/Statistic

s.htm

Organized Stroke Care

• Hamilton Health Sciences

• Kingston General Hospital

• London Health Sciences Centre

• The Ottawa Hospital

• Thunder Bay Regional Hospital

• Sudbury Regional Health Centre

• Royal Victoria Hospital ( Barrie)

• Toronto/GTA:

• St. Michael's Hospital

• Sunnybrook Health Sciences Centre

• University Health Network, Toronto

Western

• Trillium Health Centre

• In 2000, the Ontario Stroke System was developed. The OSS is a system of regional networks that were developed for stroke care delivery across Ontario.

The province was divided into 11 regional stroke networks with a regional stroke centre. There were 18 District Stroke Centres and 24 stroke prevention clinics.

The regional centers that were developed were:

Each Regional Stroke Centre and District Stroke Centre must:•Meet designation guidelines and readiness criteria including requirements based on what is currently accepted as the ‘gold standard’ in acute stroke care.

•Have additional roles including a role in organizing the human and medical resources for their region and for developing a regional plan across the continuum of care.

•Responsibility of providing leadership for the growth and development of the Ontario Stroke System for their region in partnership with the DSCs, community hospitals, community systems and other key stakeholders.

•Take the lead in developing a regional plan across the continuum of care, as well as provide the latest interventions for acute care on an urgent basis

The Ontario Stroke Network

Special Projects used in Stroke

• Stroke Special project 340 (began 2009)

– Canada Wide data collection on clinically important stroke care indicators

– Canada wide stroke report generated

– Informs provincial stroke networks

• In Ontario

– Used to Prepare the Annual Report Card

• Sites use to monitor more frequently

4 Major Policies Implemented

1. EMS Redirect protocol

• Implemented in 2004

• Systems approach to getting tPA eligible patients to designated stroke centres

2. Provincial implementation of stroke regions

• 11 Regional Stroke Centres/Networks

• 16 District Stroke Centres

• 24 Stroke Prevention Clinics

4 Major Policies continued…

3. 1st provincial and 14 LHIN report cards

• June 2011

• Released annually

4. Quality Based Programs Stroke Clinical Handbook released

• March 2013

Does it Work?

• A paper released in 2013 in the Canadian Medical Association Journal assessed the effect of the Ontario Stroke System, a province-wide strategy of regionalized stroke care delivery on stroke care outcomes in Ontario.

Effect of a Provincial System for Stroke

Full implementation of the OSS was associated with:

• An increase in rates of care at stroke centres (40-46%)• Decreased rates of discharge to long-term care facilities

(16.9%-14.8%)

• Decreased 30-day mortality for hemorrhagic stroke (38.3-34.4%)

• Decreased 30 day mortality for ischemic stroke (16.3-15.7%)

• Increased proportion of patients who received neuroimaging, thrombolytic therapy, care in a stroke unit and antithrombotic therapy

Stroke Distinction

• Stroke Distinction for Hospitals

– Certification of specialty by Accreditation Canada

– Began 2011

– Sites must submit performance on specific measures q 6 months

• Some measures included in Project 340

• Other measures manually collected at centers

Where does the information come from?

• In the past, relied heavily on the CIHI DAD plus ongoing National and Provincial Chart audits

– Timely, costly

– Delay in results

• CIHI Special Projects developed

– Efficient

– Uses the experts (CHIMs)

Beyond Project 340

• Need for further monitoring of best practice elements across Canada as evidence and practices evolve

– Project 640

• Need for evaluation of Ontario Specific measures

– Project 740

Cases included in Special Projects

• New Acute Ischemic and Hemorrhagic Stroke and Transient Ischemic Attack cases–ALL Stroke cases in Canada

• 340 and 640 - Same cohort

• 740- some cases not included!

*Refer to the CIHI Abstraction Manual

ICD codes

ICD 9 and 10 codes identified by the Canadian Stroke Network that have the highest correlation to Acute Stroke– I60.– Subarachnoid hemorrhage

– I61.– Intracerebral hemorrhage

– I63.– Cerebral infarction

– I64 Stroke, not specified as hemorrhage or infarction

– I67.6 Cerebral Venous Thrombosis

– H34.1 Central retinal artery occlusion

– G45.– Transient cerebral ischemic attacks and related syndromes

– G08- Intracranial and Intraspinal phlebitis/thrombophlebitis

What is included in each project?ICD code 340 640 740

I60 (excl. I60.8)

SAH

I61.- ICH

I63.- Cerebral Infarct

I64.- Stroke NOS

I67.6 Venous Sinus Thrombosis

H34.0Transient Retinal ArteryOcclusion

H34.1Central Retinal ArteryOcclusion

G08 Intracranial Phlebitis

G45.- TIA

Review-Elements Collected in CIHI

Special Project 340:

1. CT Scan / MRI within 24 hours

2. Admission to a Stroke Unit/ Referral to an SPC (ED cases)

3. Administration of Acute tPA

4. Date and Time of Acute tPA administration

5. Antithrombotic Medications prescribed at Discharge

6. Date and Time of Stroke Onset

Special Project 640: Canadian Stroke Strategy Performance Improvement II

• Began in July 2015

• Optional

– Connected to 340

• Additional stroke best practices that have emerged

• In line with reporting requirements for Stroke Distinction awarded by Accreditation Canada

Elements in 640

• Dysphagia Screening

• Telestroke Consultation

• Date of admission to Stroke Unit

• Date of discharge from Stroke Unit

• Emergency Room Triage Date and time

Cases for Completing 640

Criteria is the same as CIHI Special Project 340

– Both ED and Admitted Cases

• NACRS and DAD , but Stroke unit not included in NACRS abstract

– Completed ONCE during episode of care

640- NARCS and DAD fields

Element NACRS DAD

Dysphagia Screen

Telestroke Consultation

Stroke Unit admit date

Stroke Unit Discharge Date

Emergency Department Triage time

Dysphagia Screening

DAD and NACRS

• Did the patient have a standardized swallowing screen done while in hospital?

– Dysphagia in stroke patients reported as high as 65%

– Can lead to aspiration pneumonia, malnutrition

• Best practice recommendation is that ALL stroke cases have swallowing assessed using a validated measure

Swallowing Screens

• Done at bedside - by Nurses, MD’s or allied health

• STAND, TOR-BEST, 3 oz. swallow test

• Early in episode of care - can be done in ED

TIP– most facilities use one type of screen for all strokes - find out what it is!

Speech and Language Pathologist Swallowing Assessment

• SL-P Dysphagia Assessment

– SL-P’s have a broader depth of knowledge

– Assess based on their own training and practice

– May/may not use a standard tool in their assessment

• MAY HAVE BOTH SCREEN AND SLP CONSULT

– Failed screen is an indication for full assessment by an SLP.

Field Completion

Project 640 field 01

• Valid Data is Y or N

– Y=Documentation in the chart that the patient had screening for dysphagia

– N=No documentation in the chart that the patient had screening for dysphagia

Telestroke Consultation

DAD and NACRS

• Videoconference Patient Consult

• Connects patients in enabled ED’s with stroke experts for consideration of thrombolytic therapy

• Currently ONLY in ED– Should be clearly documented on ED record

• Collected regardless of whether tPA given or not!

ED in remote area

connects with a

Stroke Specialist

via secure

videoconference

Telestroke

• Allows for access to experts despite distance

• Decreases need for transfers

Telestroke Consultation

• TIPS

– Find out if your site is a Telestroke site!

– Sites will have standard orders and protocols

– Consultant faxes a consult note to be included in the patients health record.

* Telestroke cases are reconciled with Telestroke sites and OTN- check with ED team or Stroke team!

Field Completion

Project 640 field 02

• Valid Data is Y , N OR 8

– Y =Documentation in the chart that the patient had telestroke consultation

– N=No documentation in the chart that the patient had telestroke consultation

– 8= facility does not have telestroke services or capability

Stroke Unit admission and discharge

• DAD only – not included in NACRS

• Patients do better!

• HBAM indicator is 75% of patients stay is on a stroke unit

• Many patients may not start out on stroke unit

(Critical Care, Step- Down or other)

Stroke Unit Admission and discharge

• TIPS

– Facilities will identify if they have a stroke unit

• Location code or Ward

• Stroke Unit is defined by the QBP handbook with specific criteria

– Acute care only!

– If they are transferred to a stroke unit after an ICU stay, use the date they arrived on the designated unit.

ED triage time

• Part of Emergency Record

– Shift in tPA recording from DOOR to needle to TRIAGE to Needle

– DAD field that is OPTIONAL if Level 3 ED data submitted to NACRS

– If entry code is other than “E” leave blank

Field Completion

640

Fields 3-6 Admission

Fields 7-10 Discharge

MM DD

9999 if unknown

8888 if no stroke unit at the facility OR if project 340 field 2 is N (not on a stroke unit)

Special Project 740- Alpha FIM

• Ontario Specific

• Inpatient cases only (DAD)

• Mandatory as of October 2014 discharges

• Memo from MOHLTC Health Systems Delivery and Implementation Health System Funding Policy Branch 19 September 2014

AlphaFIM• AlphaFIM Instrument is recommended provincially and

nationally as a best practice in acute stroke care for all stroke admissions.

• In 2007, the Ontario Stroke System recommended to support the provincial implementation and use of the AlphaFIM Instrument in acute care to determine the stroke survivor’s functional status and impairments.

• Use of the AlphaFIM Instrument in the acute setting will facilitate linking data with the National Rehabilitation Reporting System (NRS) dataset where the FIM® Instrument (Functional Independence Measure) data are collected.

• Goal is AlphaFIM scores will become part of the common language and practice in Ontario.

AlphaFIM® and FIM® are trademarks of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.

(www.udsmr.org)

Timely Transfer of Appropriate Patients from Acute Facilities to Rehabilitation: Using the AlphaFIM® Instrument to Support Best Practice in

Stroke Care August 2014, Ontario Stroke Network

AlphaFIM

Subset of 6 elements of the Functional Independence Measure (FIM) tool

- If done day 3 post stroke it is HIGHLY predictive of the patient’s admission and discharge FIM scorein in-patient rehab

- Assists with triage of patients to next required level of care

- WE CAN PREDICT HOW THEY WILL DO AFTER THEIR STROKE

AlphaFIM

• Hospital Staff complete the assessment

• Must maintain certification every two years

• May be part of E-doc or paper chart

• Documentation will include total motor and total cognitive score, and date assessment completed.

Field Completion

Field 01

Documentation of Alpha FIM Scores

Y- Yes there is documentation

N- No documentation

Fields 02-09

Alpha FIM completion date

Year, month day,

YYMMDDHHMM

99999999 if blank

Fields 10-11

13 Raw Motor Rating

2 Characters

13-91 (Score range)

99 if blank

Fields 10-11

5 Raw Motor Rating

2 Characters

5-35 (Score range)

99 if blank

TIPS

Each hospital with have one place to document ALPHA FIM.

• Cases with a short LOS (24 hours) will likely not have one completed

• TIA not included (should have a very short stay)

• Not charted = not done

TIPS

• All hospitals in Ontario are part of a Stroke District or Region and will have a Director or Manager - Ask them questions!

• Sites with large volumes will likely have a Stroke lead or Stroke Team

• Resources available at

www.strokebestpractices.ca

Thank you to the Central South Regional Stroke Measuring and Evaluation Committee and the

CHIM’s in the Region for assisting with development and review of this package.