What Is Primary Stroke Center Certification?

1. Quality Improvement In Stroke Care For Primary Stroke Center Certification at St. Francis Health Center Washburn University Master’s 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 master’s 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 patient’s 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 < 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 < 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_measure_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/mmwrhtml/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/index_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 Saver, J. L., Smith, E. E., Fonarow, G. C., Reeves, M. J., Zhao, X., Olson, D. M., et al. (2010). The “Golden Hour” and Acute Brain Ischemia. Stroke: Journal of The American Heart Association , 1431-1439.