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Assessing Treat and Ship Performance: Adding Value to a Small Rural Hospital Collaborative

Abstract. . Although quality of care measures developed by CMS and JCAHO can be used to assess care in medium to large facilities, a number of the measures are not as useful for the very small and critical access hospitals due to both low overall patient volume and the volume of trans

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Assessing Treat and Ship Performance: Adding Value to a Small Rural Hospital Collaborative

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    1. Assessing Treat and Ship Performance: Adding Value to a Small Rural Hospital Collaborative Barbara B. Okerson, Ph.D.,CPHQ Edna Rensing, MSHA, RN, CPHQ

    2. Abstract

    3. The D-squared (D2) collaborative Naming the collaborative Documentation Project already underway D-Squared for Discharge Documentation Identification of population Mapping of critical access and rural hospitals Compute baseline rates Identification of disparity (rural vs. overall) in Virginia HF Discharge instructions Smoking cessation counseling

    4. Collaborative goals Increase collaboration between small rural hospitals in Virginia. Decrease disparity between small rural hospitals and larger facilities. Make sample sizes more meaningful by addressing indicators at hospital level rather than topic level. Provide indicators customized for small hospitals.

    5. Partner support Virginia Department of Health (VDH) Center for Primary Care and Rural Health Virginia Cardiovascular Health Project (VCHP) Healthy Pathway Coalition Virginia Rural Health Association (VRHA) Alliance for the Prevention and Treatment of Nicotine Addiction (APTNA) QIO support through QIOSCs Qualis Health (Collaborative QIOSC) Oklahoma Foundation for Medical Quality (Infectious Diseases QIOSC) Colorado Foundation for Medical Care (Heartcare QIOSC)

    6. Literature review Differences/lack of agreement in literature Transfer window times for stroke and AMI Who should be transferred Importance of timely transfer stressed

    7. Literature review selection: importance of AMI transfer time When transport is required, primary PCI remains a superior strategy to local thrombolysis, as long as transfer time is <3 hours. Combined criteria (CC) of death/reinfarction/stroke reduced by 45%. Dalby M, Bouzamondo A, Lechat P, Montalescot G. “Transfer for Primary Angioplasty Versus Immediate Thrombolysis in Acute Myocardial Infarction: A Meta-Analysis” Circulation. 2003;108:1809-1814.

    8. Literature review selection: importance of AMI transfer time Transferring a patient for primary angioplasty is the best strategy as long as the patient is transferred in less than one hour (transfer time includes prepping cath lab and patient for angioplasty). 15% decrease in adverse events (death, stroke, recurrent MI) and a 37% decrease in hemorrhagic complications. Niles, N.“DHMC Acute MI Protocol Reducing Mortality”, Dartmouth-Hitchcock Medical Center, 2003. http://www.dartmouth.edu/~cardio/news/AMI%20Protocol.htm

    9. Literature review selection: importance of stroke transfer time Necessary availability of diagnostic studies available 24-h/day and 7-d/week basis. If not available, rapid transfer to institution where available. Treatment requires the patient to be at an experienced stroke center with immediate access to cerebral angiography and interventional neuroradiology. Delays may lessen the utility of intra-arterial thrombolysis in treating acute ischemic stroke. Timely treatment equals statistically significant improved mortalities. Adams HP Jr, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatkowski TG, Marler JR, Hademenos GJ; Stroke Council of the American Stroke Association “Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association.” Stroke 2003 Apr;34(4):1056-83.

    10. Literature review selection: importance of stroke transfer time With intra-arterial (IA) thrombolytic therapy treatment window expanded to < 6 hours from onset. If onset of stroke or last seen normal < 3 hours, patient should be considered a candidate for transfer from non stroke center hospitals. The door to transfer time should be completed within 20 minutes, because any delay puts the patient at risk. Tanne, D. et al. “Intravenous rt-PA therapy for stroke in Clinical Practice: A multi-center evaluation of outcome.,” Stroke, 1998: 29:1.288. Barch, CA, “Treatment window for acute ischemic stroke is expanding”, Stroke Matters, April 1999.

    11. Literature review selection: importance of stroke transfer time Transfer of stroke patients can be costly. Costs per additional good outcome and per quality-adjusted life-year (QALY) were calculated. Absolute increase in good outcomes was as high as 20% with cost factored in. Silbergleit R, Scott PA, Lowell MJ, Silbergleit R., “Cost-effectiveness of helicopter transport of stroke patients for thrombolysis,” Acad Emerg Med. 2003 Sep;10(9):966-72.

    12. Measures background -AMI Recognize the improved mortality of AMI patients with primary PTCA, also: Lower rates of stroke. Lower rates of recurrent ischemia an reinfarction. Recognize small hospitals without cardiac surgery programs need to transfer to interventional center. Recognition by emergency personnel when to transfer and what to do before transfer. Understand risks – transfer and delay of transfer.

    13. Measures background - stroke National Institute of Neurological Disorders, National Stroke Association and other guidelines. Optimal treatment includes access to primary stroke centers that provide: 24/7 physician staffed emergency department. A defined acute stroke team (should include emergency department staff). Neuroimaging services (24/7). Laboratory services (24/7). Inpatient services appropriate to the patient's level of illness with close neurological and cardiorespiratory monitoring. Importance of timely transfer of patients to primary stroke center by small hospitals.

    14. Inclusion of “treat and ship” measures Requested by potential collaborative participants. Supported by clinical guidelines. Small hospitals motivated to track and improve transfer processes. Transfer patients excluded from CMS and JCAHO indicators. Interest expressed by CMS.

    15. CMS interest Hospitals in several states that routinely transfer AMI patients sought assistance in assessing performance. QIOs provide support to Critical Access Hospitals. National call on March 10, 2003 by Heartcare Support QIO (Colorado).

    16. Treat and ship measures for D2 (optional) AMI transfer patients receiving risk assessment, aspirin administration, beta blocker administration, pain management, monitoring, rhythm management, clot-busting. 62% of collaborative members tracking 13% plan to track in future Stroke transfer patients receiving risk assessment, monitoring, clot-busting. 50% of collaborative members tracking 13% plan to track in future

    17. D2 optional measures Staff who are knowledgeable in AMI and stroke practices. 50% of collaborative members tracking 25% plan to track in future Time from presentation at small hospital emergency room to transfer to larger facility. 62% of collaborative members tracking

    18. D2 optional measures Hours per day transfer transportation available. 38% of collaborative members tracking Door to drug time for stroke patients. 50% of collaborative members tracking 13% plan to track in future Door to drug time for AMI patients. 62% of collaborative members tracking 13% plan to track in future

    19. “Treat and ship” protocols/pathways 25% of collaborative members have in place. 13% have planned.

    20. Other measures tracked by D2 hospitals Time clot bust given (AMI). Time to transportation arrival at transferring facility. Compliance with stroke collaborative protocol for “evaluation for ship”.

    21. Rural hospitals – what are the real issues? TIME Symptom to Door (EMS or Patient). Door to tests (EKG or CT). Tests or availability of personnel Test to treatment (PTCA or thrombolytic). Reading the tests Distance: Door to transfer facility Follow-up. Specialties available if complications

    22. Transportation issue details from collaborative participants Bed back-up More ICU patients than ICU beds at transferring hospital. More patients than licensed beds at transferring hospital. Unable to transfer because receiving facility at capacity. Reimbursement issues. Weather Snow and ice impact transportation. Hurricane Isabel. Availability All available transportation already in use. Distance Distance to receiving hospital compromises window of opportunity without air transportation available.

    23. Staffing issue details from collaborative participants Differing physician philosophy. Difficult to adopt protocol/pathway. Delay waiting for physician decisions. Nursing and physician staffing (sub specialist/ specialist) on both ends. ED staffing without specialists on both ends of transfer. Backlog for tests, radiology, etc. because of small number of staff.

    24. Other issues from collaborative participants Hospital administrative issues. Sometimes administrative approval is required before receiving hospital will accept – causes delay. Patient waits too long to report symptoms and presents-they become excluded. Patient does not recognize symptoms. Distance patient traveled to community hospital uses time window.

    25. Next steps Continue working with the hospitals. Continue working with our partners and forge new partnerships. Continue sharing information with other QIOs. Consider multi-QIO project.

    26. Sample stroke transfer checklist

    27. Questions

    28. Contact information Barbara B. Okerson, Ph.D., CPHQ bokerson@vaqio.sdps.org Edna Rensing, M.S.H.A., RN, CPHQ erensing@vaqio.sdps.org

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