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Quality Improvement and Performance Indicators for Primary Stroke Center Certification at St. Francis Health Center
Jill Collins
Washburn University
NU 670
Dr. Monica Scheibmeir
December 5th, 2012
Quality Improvement and Performance Indicators for Primary Stroke Center Certification at St. Francis Health Center
Introduction
Cerebrovascular accident (CVA), also referred to as a stroke in the lay literature, is the third-leading cause of death and the leading cause of disability annually in the United States (Leifer, et al., 2011). An estimated 795,000 people in the United States are diagnosed with a CVA each year. For more than 600,000 of these Americans, this will be their first CVA but almost 200,000 of the yearly CVAs are recurrences (George, Tong, & Yoon, 2011). Approximately 140,000 CVA deaths occur annually and in addition, it is listed as a contributing factor in another 100,000 deaths (Katz, 2010). With the steady incline in medical conditions putting people at risk for a CVA including obesity, hypertension, dyslipidemia and diabetes, these numbers will likely continue to rise. The resulting effects will cost consumers millions of dollars in both direct healthcare costs as well as loss of productivity and income secondary to the profound and devistating disabilities resulting from a CVA. In 2010, an estimated $73.7 billion was spent on CVA-related medical costs and disability alone (Otwell, Phillippe, & Dixon, 2010). This project will assist St. Francis Health Center in collecting data on their current management of stroke care. The data can then be used to improve the care provided by St. Francis Health Center to victims of cerebrovascular accidents.
Pathophysiology
Before discussing the evaluation of stroke care, it is important to review and understand the anatomy and pathophysiology of the underlying disease. This makes it easier to understand why certain criteria are chosen to evaluate appropriate care. The brain is a relatively small part in the human body occupying only 2% of the bodys mass. However, it receives 17% of the hearts output and consumes 20% of the bodys oxygen supply. The brain receives its vital blood supply through four arteries. The two largest arteries are the right and left internal carotids which branch off the left and right common carotids respectively and travel up the anterior portion of the neck. The common carotids arise from the aorta. These internal carotids give rise to the middle and anterior cerebral arteries which supply blood to the anterior portion of the brain including most of the frontal, parietal and temporal hemispheres as well as the basal ganglia. There are also two smaller arteries that travel up the posterior portion of the neck and are the right and left vertebral arteries. These arteries arise from a single basilar artery. The basilar artery arises from a branch off the subclavian artery which in turn branches off the aorta. These arteries supply blood to the posterior portion of the brain including the brainstem, cerebellum and most of the posterior cerebral hemispheres. The anterior and posterior circulations connect through a circular anastamosis of arteries called the Circle of Willis. The brain receives about 80% of its blood supply from the carotid arteries and the remaining 20% from the vertebral arteries (Katz, 2010).
One characteristic of the brain is many of its functions are not diffusely spread meaning specific neurologic functions are dependent on certain brain regions. In the cerebral vasculature, each artery supplies a particular brain region. Because most of these regions are associated with a characteristic neurological function, damage to a particular cerebral artery tends to cause characteristic losses of neurological functions which are often referred to as focal neurological deficits (Appendix A) (Katz, 2010).
Cerebrovascular accidents can be broadly defined as an interruption in blood supply to the cells which compose brain tissue and are classified as either ischemic or hemorrhagic. This can sometimes be confusing though because both actually cause ischemic damage. In the case of an ischemic stroke, resulting injury to brain tissue is caused by a reduced blood flow to a specific region without initially causing significant cerebral bleeding. This reduction in blood flow is most often secondary to a blocked artery but can also occur as a result of hypoprofusion as in the case of sustained cardiac arrest. Hemorrhagic strokes result from injuries that cause bleeding into the brain or cerebral spinal fluid from the outset. This bleeding is generally due to a tear in an artery or the rupture of an aneurysm. These conditions are often secondary complications from conditions such as hypertension, tumors or drugs. They can also be the result of trauma or physical activity. The majority of strokes (87%) are ischemic from the outset and as mentioned above, are primarily caused by the blockage of an artery. This blockage is predominantly due to a thrombus or blood clot (Katz, 2010).
Ischemic strokes, as the name implies, cause ischemic damage which is either complete or incomplete. If the blood supply to the brain is cut off completely, as is the case with cardiac arrest, there is widespread cell damage and neurons begin to die quickly. The brain uses energy quickly but only has a small back-up supply. When complete ischemia occurs, there is an immediate decrease in available oxygen and glucose that brain cells need to survive. Local neurons will begin to run short on their internal ATP (the back-up intracelluar energy stores) within a matter of seconds. As ATP is depleted, the cell membranes depolarize and extracellular ions rush in. This leads in water accumulation in the cells and eventually causes the cell to self-destruct, burst and die. This process is also known as apoptosis. As cells die in this manner, the toxic substances released from them can have a detrimental domino effect on surrounding cells which will continue until the blood supply is re-established (Katz, 2010).
Most ischemic strokes are not a result of complete ischemia. They are primarily caused by incomplete ischemia as a result of a partially or completely blocked artery. These blockages are generally caused by a blood clot or thrombus. The thrombus itself is usually the result of other conditions including but not limited to coagulopathies, atrial fibrillation and atherosclerosis. Even when an artery is competely occluded, the cerebral circulation has many overlaps and interconnections. Some blood will usually reach the affected brain regions via collateral circulation. The remaining perfusion will vary throughout the affected region. A common pattern is severely reduced perfusion in the center with gradually increasing profusion toward the edges. The area of minimally profused cells is referred to as the pneumbra. Neurons will become functionally silent when arterial profusion drops by even a small amount. In the case of a stroke, as soon as the cerebral blood flow is reduced, electrical activity in the region will stop and neurological deficits begin to appear. For a short time, silent neurons remain alive but no longer have the energy to generate membrane potentials sufficient enough to respond to stimuli or transmit signals. To remain alive, these neurons need some arterial profusion and if cerebral blood flow falls below 13% of normal in the affected region, silent neurons begin to die in the same fashion as complete ischemia.
The amount of irreversible damage increases steadily as long as regions are without sufficient blood supply. If the affected areas have no blood flow, neurons begin to die in less than 10 minutes. In areas with <30% of normal blood flow, neurons begin to die within an hour. In areas with 30-40% of normal blood flow, some neurons will die within an hour but others can be revived after many hours. In has been found that collateral and residual blood flow can preserve neurons in the pneumbra and border areas for as long as six hours after an ischemic stroke. If treatments are given within this time period to destroy the thrombus, there may be a reduction in the amount of irreversible brain damage.
Fortunately, in most ischemic strokes, patients lose neurologic functions early in the course before all the neurons in the affected area are irreversibly damaged. Typically, most strokes leave enough arterial perfusion that many neurons can maintain a low level of energy production sufficient enough to slow the onset of their death. This is why early recognition of stroke symptoms and early initiation of thrombotic administration in the appropriate candidate is crucial (Katz, 2010).
Hemorrhagic strokes result in a release of blood into the brain parenchyma or cerebrospinal fluid (CSF) and produce damage by three mechanisms: ischemia, physical destruction and pressure. Hemorrhagic strokes produce ischemia by diverting blood from cerebral arteries and by pressure from a hematoma or edema also causing contstriction. Bleeding into the CSF raises intracranial pressure which will also reduce cerebral blood flow. Physical destruction is a result of blood flowing extracellularly in the brain parenchyma which pushes cells apart, dissects brain tissue, destroys connections and injures brain cells. Excessive pressure resulting from a hematoma or cerebral edema can cause brain herniation which can irreversibly damage brain regions such as the reticular activating system or the respiratory control nuclei and result in coma or death. Global compression caused by increased intracranial pressure from a hemorrhagic stroke can lead to cardiovascular malfunction which may result in reduced consciousness, global brain ischemia and death (Katz, 2010).
Risk factors for cerebrovascular accident include: atrial fibrillation, hypertension, diabetes, dyslipidemia, smoking, recreational drug use, obesity, history of prosthetic heart valve, hormone replacement therapy, coronary artery disease, family history of stroke, history of previous stroke, peripheral vascular disease, carotid stenosis, alcohol abuse, previous transient ischemic attack and renal insufficiency.
Significance for Healthcare
The injury to the brain and resulting disabilities caused by a CVA can be minimized or even reversed if treated properly and quickly by specialized teams utilizing the most current evidence-based practice guidelines for CVA care. Significant amounts of money and time have been spent on research to develop these evidence-based practices which are established through knowledge of the pathophysiology and risk factors for stroke.
Medicare and The Joint Commission, which is the nations oldest and largest standards-setting and accrediting body in health care, took eight of the above mentioned guidelines and put them into a core measure set for stroke care (Appendix B). Performance in core measure sets is a method for Medicare and The Joint Commission to identify and prioritize unresolved issues regarding healthcare performance. Core measures also play an important role in establishing and keeping The Joint Commissions accreditation and receiving Medicare reimbursement. The guidelines for core measures were established after solicitation by The Joint Commission from a wide variety of stakeholders including clinical professionals, healthcare provider organizations, state hospital associations and healthcare consumers. The Joint Commission also has core measure sets for the management and treatment of myocardial infarction, congestive heart failure, pneumonia and surgical infections (Core Measure Sets: Stroke, 2011).
Quality Improvement
The recommendations and requirements set forth by The Joint Commission for hospitals to comply with what is considered competent and quality care for any given condition are vast and ever-evolving. In an effort to keep abreast of these recommendations and requirements, internally monitor performance, implement changes and re-evaluate those changes, many healthcare facilities established quality improvement departments.
Quality improvement works off the basis of outcomes research. Outcomes research examines the effects of healthcare interventions and policies on health outcomes for individual patients and populations in routine practice. This is opposed to the idealized setting of clinical trials (Ting, Shojania, Montori, & Bradley, 2009). Despite efforts made by healthcare organizations to meet standards, there still remains a significant gap between ideal and actual care. Quality improvement research strives to bridge this gap.
Humans have been intrigued by the complex science of healing others for many years but the science of measuring and improving the quality of delivered healthcare is a fairly recent undertaking. It began only a century ago when a Boston surgeon named Ernest A. Codman started his end results system. This system tracked surgical outcomes in order to improve surgical practice. His work in this area ultimately led to the creation of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) which has now been shortened to The Joint Commission (TJC). Despite his efforts, the science of healthcare quality improvement only took root a generation ago. There were three major catalysts for this. The first was the transcendence of medicines status as an anecdotal, non-evidence-based area of practice into one in which good data led to the discovery of improved treatment practices. The remaining two were the increase in public demand for greater provider accountability and positive patient outcomes and the implementation of value-based purchasing (Shojania, McDonald, Wachter, & Owens, 2004).
By the mid 1990s, the influences of clinical treatment information, increased consumer and purchaser knowledge, skepticism of the medical communitys ability to ensure high-quality healthcare and the science of quality measurement had come together. There had been many more studies by this time revealing the large gap between the findings of the studies and their practical application. These studies indicated research into quality healthcare does not ensure the patient will receive the highest quality of care. From this, a new area of inquiry was created and became the way to best translate research into practice or quality improvement (Shojania, McDonald, Wachter, & Owens, 2004).
Purpose
In an effort to raise the bar for hospital stroke care, The Joint Commission initiated the Primary Stroke Center Certification Program in December of 2003. This program was developed in collaboration with the American Heart Association/American Stroke Association and recognizes centers who follow best practices for stroke care (The Joint Commission, 2012).
Obtaining initial Primary Stroke Center Certification is a very rigorous process. It requires meeting several standards published in the Disease-Specific Care Certification Manual as well as meeting many other clinically specific requirements and expectations (Appendix C). One of these specific requirements is that the program have an organized and comprehensive approach to measuring data and utilizing it for performance improvement processes. The Disease-Specific Care Certification Manual recommends that Stroke Centers utilize a database or registry for tracking the number and type of patients with stroke seen, their treatments, timelines for receiving treatments, and some measurement of their outcomes (Alberts, et al., 2011). The data must be internally trended over time and may be compared to an external data source for comparative purposes. One of the recommended databases to use, as set forth by The Joint Commission, is the American Stroke Associations Get With the Guidelines-Stroke registry. This allows for a center to input their data into a large database, analyze the data to identify improvement opportunites and compare data with hundreds of other participating centers across the state, region and nation.
St. Francis Health Center recently elected to apply for Primary Stroke Center Certification to ensure its customers receive the best possible care if they or their loved ones should ever experience a cerebrovascular accident. The purpose of this project is to establish the Get With the Guidelines-Stroke registry at St. Francis Health Center. This will aid the center in both obtaining Primary Stroke Center Certification and identifying areas for potential improvement in stroke care.
Significance For Nursing
Many of the quality indicators for stroke are a direct reflection of nursing care. Nurses are the front line for patients in a hospital setting assuring that quality indicators are achieved. This applies not only to bedside nurses but also to nurses working in quality improvement. These nurses specifically monitor for compliance with core measures and quality indicators. Nurses need to remain educated and up to date on current recommendations on best practices for stroke care to assure the best possible outcomes for consumers. This project will be aimed at identifying areas in which nursing, as well as other disciplines, can improve practices leading to a decline in death and disability as a result of stroke at St. Francis Health Center.
Project Objectives
The following objectives will be met at the end of implementation of this project:
The American Stoke Associations Get With the Guidelines-Stroke registry database will be established at St. Francis Health Center. The American Stroke Association recommends a baseline of thirty chart reviews/entries be completed based on the estimated number of CVAs treated at this facility annually for comparison to current data. For this project, thirty charts from January 1st, 2011 through June 30th, 2011 will be randomly chosen and retrospectively reviewed to provide baseline data. Starting July 1st, 2011, all charts with a qualifying final diagnosis code related to CVA will be retrospectively reviewed and recommended data will be extracted and entered into the registry database. By the end of this project, all qualifying charts through August 30th, 2012 will be entered into the database.
Performance data for all charts entered into the registry for St. Francis Health Center through August 31st, 2012 will be analyzed and a powerpoint presentation will be made to provide to the quality department for review. This presentation should both show what is being done well and identify opportunities for improvement in the quality of stroke care provided by St. Francis Health Center. The information in this presentation will incorporate data from the registry including demographics, performance on current stroke core measure components and performance in regard to current recommendations by the American Heart Association/American Stroke Association for The Golden Hour of stroke care. This includes CT done within 25 minutes of arrival and IV tPA initiated within 60 minutes of arrival.
Implementation
Prior to initiating the project and data collection, I received approval from Scott Wells, CNO of St. Francis Health Center and Mary Claire Wilson, Director of Quality Improvement. I also received approval from the Washburn University IRB to complete the data collection.
A member of the accounting department at St. Francis Health Center was designated by the quality department to generate a list of patients whose discharge diagnoses included an ICD-9 cerebrovascular accident related code. These codes have been pre-determined by the American Stroke Association and The Joint Commission and include codes related to: ischemic stroke, transient ischemic attack, subarachnoid hemorrhage, intracerebral hemorrhage and strokes not otherwise specified. This list began with patients discharged after January 1st, 2011 and ended with those discharged before September 1st, 2012.
The above list was provided to myself for review to determine which patients qualified for entry into the registry database. Some of the patients needed to be excluded. The registry does not include anyone under the age of 18. The patients primary reason for admission had to be for stroke-like symptoms at the time of or immediately before admission or during their hospital stay. This excluded patients who presented for elective carotid surgery because they had a previous stroke or TIA caused by carotid stenosis.
Each qualifying patient was assigned a random identifying number. This number was attached to the patients account number in a log available in the supervisors drive in the hospital computer system. This drive can only be accessed by anyone in a supervisory position including the Stroke Coordinator of the hospital. This process ensures the patient information is kept anonymous. There was no personal contact with any patient. Confidentiality was maintained throughout the project and thereafter following the Health Insurance Portability and Accountability Act (HIPPA).
The American Stroke Association has very specific information that is to be extracted from the patient chart. To aid in doing this, they have created a worksheet for the Get With the Guidelines-Stroke database which is managed by Outcome Sciences Inc. (Outcome Sciences Inc., 2009). This information relates directly to the core measure elements for stroke set forth by The Joint Commission as well as other pertinent patient management information. For a complete listing of data to be extracted, please refer to Appendix D. I used this worksheet to guide data extraction from the charts. Initially, I retrospectively reviewed thirty charts with a discharge date falling between January 1st, 2011 and June 31st, 2011. Data was extracted according to the recommendations and this information was entered into the computerized registry database. This information serves as baseline data. I then retrospectively reviewed all charts with discharge dates falling on or after July 1st, 2011 through August 31st, 2012. I extracted the appropriate data and entered it into the registry. In all, I spent over 100 hours entering 218 charts into the Get With the Guidelines-Stroke database for St. Francis Health Center.
I then reviewed and analyzed the data entered. Results from this review are shared in the data findings section. This information was put into a powerpoint presentation and given to Tiffany Noller who is the Quality Department manager, my preceptor and committee member for this project. She may choose to use this powerpoint as an educational tool to emphasize components that are currently being done well and identifying areas that need improvement.
The Joint Commission surveyor did come to St. Francis Health Center in July of 2012 for site evaluation for Primary Stroke Center Certification. The surveryor did note areas for improvement but granted St. Francis Health Center the designation of a Primary Stroke Center on September 13th, 2012. The initiation of the registry database and the current information was shared with the surveyor at the time of the site visit. This allowed St. Francis Health Center to show that they were meeting specific requirements for certification. The requirements met by this project are: analyzing and using standardized performance measure data to continually improve treatment plans and demonstrating application of and compliance with cinical practice guidelines published by the American Heart Association/American Stroke Association or equivalent evidence-based guidelines. At the time of the site evaluation, the American Heart Association had also granted St. Francis Health Center the bronze award for having 4 consecutive months of data entered into the database. At the end of this project, 12 consecutive months of data have been entered into the database which should qualify St. Francis Health Center for the gold award as well.
Data Findings
In this section, I will cover data reviewed and analyzed from the Get With the Guidelines-Stroke database registry. With each item, I have included rationale for why I chose this item as well as additional explanation of the item if needed. For purposes of this section, baseline data will refer to chart reviews from January 1st, 2011 through June 30th, 2011. 2011 data will refer to all qualifying chart reveiws from July 1st, 2011 through December 31st, 2011. Current data will refer to all qualifying chart reviews from January 1st, 2012 through August 31st, 2012. As mentioned before, data was extracted for 30 random charts in the baseline data and 188 charts from 2011 data and current data however not all charts qualify for every component of analysis. For example, patients with hemorrhagic strokes are automatically taken out of consideration for antithrombotic administration by the end of hospital day 2 for obvious reasons. The all hospitals data is an average of how all hospitals in the registry are performing from January 1st, 2012 through August 31st, 2012 and allows for external comparison during the same time period as current data.
Demographics
It is important for a facility to be familiar with the population it is treating for a particular diagnosis in order to know who to target for community education.
Demographics included in the registry and specific to St. Francis Health Center during the current data time frame:
Gender:
Female: 62%
Male: 38%
Age:
18-45 years: 2%
46-65 years: 26%
66-85 years: 56%
>85 years: 16%
Average age: 72 years
Race:
White: 87%
Black or African American: 10%
Hispanic: 2%
American Indian: 1%
Stroke Core Measure Set Performance Indicators
Stroke core measure set performance indicators are those items reviewed by The Joint Commission as part of the credentialing process as well as determining reimbursement rates for stroke care. The specific performance indicators are as follows:
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). Results of compliance for St. Francis Health Center are as follows:
Baseline Data: 83% of qualifying patients received VTE prophylaxis
2011 Data: 100% of qualifying patients received VTE prophylaxis.
Current Data: 82% of qualifying patients received VTE prophylaxis
All Hospitals: 92% of qualifying patients received VTE prophylaxis
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). Results for compliance for St. Francis Health Center are as follows:
Baseline Data: 100% of stroke patients were discharged on antithrombotic
2011 Data: 98.5% of stroke patients were discharged on antithrombotic
Current Data: 98.6% of stroke patients were discharged on antithrombotic
All Hospitals: 98% of stroke patients were discharged on antithrombotics
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 treatement 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%. Results for compliance for St. Francis Health Center are as follows:
Baseline Data: 100% of patients with afib/aflutter were discharged on antithrombotics
2011 Data: 82% of patients with afib/aflutter were discharged on antithrombotics
Current Data: 67% of patients with afib/afutter were discharged on antithrombotics
All Hospitals: 93% of patients with afib/aflutter were discharged on antithrombotics
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 (Appendix E). 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 U.S. all recommend the use of IV tPA for eligible patients (Outcome Sciences Inc., 2011). Results for compliance for St. Francis Health Center are as follows:
Baseline Data: 57% of eligible patients received IV tPA within the 3 hour time window
2011 Data: 70% of eligible patients received IV tPA within the 3 hour time window
Current Data: 78% of eligible patients received IV tPA within the 3 hour time window
All Hospitals: 79% of elegible patients received IV tPA within the 3 hour time limit
Early antithrombotics. Patients with ischemic stroke or transient ischemic attack should receive anithrombotic 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 (Outcome Sciences Inc., 2011). Results for compliance for St. Francis Health Center are as follows:
Baseline Data: 100% of qualifying patients received early antithrombotic therapy
2011 Data: 97% of qualifying patients received early antithrombotic therapy
Current Data: 98% of qualifying patients received early antithrombotic therapy
All Hospitals: 97% of qualifying patients received early antithrombotic therapy
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 (Outcome Sciences Inc., 2011). Results for compliance for St. Francis Health Center are as follows:
Baseline Data: 81% of qualifying patients were discharged on a statin or had a documented reason for why this was not done.
2011 Data: 89% of qualifying patients were discharged on a statin or had a documented reason for why this was not done
Current Data: 93% of qualifying patients were discharged on a statin or had a documented reason for why this was not done.
All Hospitals: 92% of qualifying patients were discharged on a statin or had a documented reason for why this was not done.
Stroke Education. Patients with stroke or transient ischemic attack or their caregivers should be given 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). Results for compliance for St. Francis Health Center are as follows:
Baseline Data: 57% of patients received recommended stroke education before discharge.
2011 Data: 64.5% of patients received recommended stroke education before discharge.
Current Data: 86% of patients received recommended stroke education before discharge.
All Hospitals: 89% of patients received recommended stroke education before discharge.
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 patients 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). Results for compliance for St. Francis Health Center are as follows:
Baseline Data: 100% of stroke patients were assessed for rehab needs.
2011 Data: 100% of stroke patients were assessed for rehab needs.
Current Data: 100% of stroke patients were assesed for rehab needs.
All Hospitals: 97% of stroke patients were assessed for rehab needs.
Stroke Golden Hour Recommendations:
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 (http://www.strokecarenow.com/pdfs/NIH_Stroke_Scale_with_picture_&_word_tools.pdf), CT scan of the brain done within 25 minutes and interpreted by a radiologist and review of eligibility for tPA. Results of key items related to The Golden Hour are as follows:
Door to CT < 25 minutes:
Baseline Data: 52% of qualifying patients had CT done in less than 25 minutes
2011 Data: 26% of qualifying patients had CT done in less than 25 minutes
Current Data: 39.5% of qualifying patients had CT done in less than 25 minutes
All Hospitals: 27% of qualifying patients had CT done in less than 25 minutes
NIHSS reported:
Baseline Data: 64% of stroke patients had an initial stroke scale completed.
2011 Data: 53% of stroke patients had an initial stroke scale completed.
Current Data: 78.5% of stroke patients had an initial stroke scale completed.
All Hospitals: 73% of stroke patients had an initial stroke scale completed
Door-to-needle time within 60 minutes
Baseline Data: 0% of qualifying patients received IV tPA within the recommended 60 minute time frame.
2011 Data: 37.5% of qualifying patients received IV tPA within the recommended 60 minute time frame.
Current Data: 50% of qualifying patients received IV tPA within the recommended 60 minute time frame. The average time is 76 minutes.
All Hospitals: 39% of qualifying patients received IV tPA within the recommended 60 minute time frame.
Miscellaneous Data
These are items that also play and important role in both the care and knowledge of stroke.
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. Please see Appendix F for a sample dysphagia screening tool used by Shore Health System a part of University of Maryland Medical System. This can also be found at http://doctors.shorehealth.org/nursing/pdf/DYSPHAGIA.pdf.
Baseline Data: 78% of stroke patients had dysphagia screen prior to taking anything orally.
2011 Data: 54% of stroke patients had dysphagia screen prior to taking anything orally.
Current Data: 79% of stroke patients had dysphagia screen prior to taking anything orally.
All Hospitals: 82% of stroke patients had dysphagia screen prior to taking anything orally.
Type of strokes treated. This shows that our patient composition for stroke fits what is typical for stroke data nationwide.
Ischemic stroke: 87%
Hemorrhagic stroke: 13%
Pre-existing conditions. This illustrates why these conditions are listed as risk factors for stroke and why the database asks about patients being discharged on antihypertensives and a Hemoglobin A1c is suggested with labwork. This is in addition to the LDL levels and discharge on statin and antithrombotic as mentioned previously.
Hypertension: 80%
Dyslipidemia: 52%
Previous stroke/TIA: 39%
Diabetes: 32%
Coronary Artery Disease: 21%
Atrial fib/flutter: 20%
Smoker: 17%
Smoking cessation education. Smoking is a common and modifiable risk factor for stroke. Education and assistance are key to eliminating this risk factor.
Baseline Data: 100% of stroke patients received smoking cessation education.
2011 Data: 100% of stroke patients received smoking cessation education.
Current Data: 100% of stroke patients received smoking cessation education.
All Hospitals: 97% of stroke patients received smoking cessation education.
Conclusion/Recommendations
Overall, St. Francis Health Center is currently performing very well in most aspects of stroke care. Even in the areas that are not ideal, they still compare well to hospitals across the nation. They actually began monitoring core measure data in regard to stroke in 2009 knowing that it would become a requirement of The Joint Commission. In response to their findings with this data, they originally developed a stroke order set in March 2010 for physicians to use to assure they were covering all requirements of The Joint Commission. This has since undergone several revisions. By June 2012, St. Francis had created the position of Stroke Coordinator in order to monitor stroke performance, educate on areas for improvement and to work on completing items for The Joint Commission survey for certification. This was originally established as a position solely for managing stroke as well as chest pain accreditation but has since been added to the many duties the Emergency Department director. Many of the improvements from baseline to current data can be attributed to the initial addition of this position and the function of the original person in it especially in regard to the improvements made during the golden hour. These have all been important steps to improving quality stroke care.
The primary recommendation would be for further education to be provided in regard to what the components of quality stroke care are. I know as a nurse in this particular facitily and soon to be provider, the primary reason I would not be performing up to standards would be because I am not aware of the expectations and current recommendations. In fact, if I would not have completed this project, I would not be aware of many of the current guidelines and recommendations and their importance. I am much more apt to be compliant if I know the reasoning behind what I am asked to do.
The primary areas of low performance have to do with the time that the patient spends in the Emergency Department so I would recommend spending a significant amount of time targeting education toward staff in this area. Posters, checklists and friendly competition are all items that I can say from my many years of experience in this department work well in this area.
I think it would be very helpful to have a stroke coordinator whose sole job is to address issues and educate staff. The stroke coordinator currently is not only in charge of maintaining stroke certification but is also responsible for maintaining chest pain education and certification as well as being the director over two large departments within the hospital. I think this allows little time for the attention that needs to be given to improving stroke care.
I would also recommend holding accountability to all staff members including physicians in regard to making sure appropriate order sets are initiated and policies and procedures are followed. I noticed in chart reviews that St. Francis has already developed a discharge checklist for stroke to assure that all aspects of core measures were addressed during the hospital stay. I rarely saw this used and think it would be very helpful.
Again, St. Francis Health Center is doing an excellent job in working toward perfecting stroke care for its patrons. The staff is very dedicated to doing what is best for the patient and with some additional education on what to do to improve and why, the numbers will continue to improve.
References
(2009). Retrieved November 26, 2012, from Stroke Care Now:
http://www.strokecarenow.com/for_healthcare_providers/inclusion_exclusion.html
http://www.strokecarenow.com/pdfs/NIH_Stroke_Scale_with_picture_&_word_tools.pdf
(2012). Retrieved July 3rd, 2012, from The Joint Commission:
http://www.jointcommission.org/core_measure_sets.aspx?=y
Alberts, M. J., Latchaw, R. E., Jagoda, A., Wechsler, L. R., Crocco, T., George, M. G., et al.
(2011). Revised and Updated Recommendations for the Establishment of Primary Stroke
Centers: A Summary Statement From the Brain Attack Coalition. Stroke: Journal of the
American Heart Association , 2652-2664.
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.
Shojania, K. G., McDonald, K. M., Wachter, R. M., & Owens, D. K. (2004, August). Closing
The Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 1
Series Overview and Methodology. Retrieved August 2, 2012, from NCBI:
http://www.ncbi.nlm.nih.gov/books/NBK43908/pdf/TOC.pdf
Table of Appendicies
Review of Cerebral Arteries.APPENDIX A
Elements of Stroke Core Measure Set..APPENDIX B
Disease-Specific Care Certification Manual Standards...APPENDIX C
Data Entry Items for Get With the Guidelines-Stroke registryAPPENDIX D
Inclusion/Exclusion Criteria for IV tPA administration..APPENDIX E
Sample Dysphagia ScreenAPPENDIX F
APPENDIX A
Cerebral Artery
Regions AffectedPossible Neurological FindingsAnterior Cerebral ArteryFrontal regions on the medial surface of of the brain
much of the corpus callosum
part of the internal capsule
regions of the basal ganglialoss of discriminatory sensation and weakness or paralysis of the contralateral foot and leg
possibly deficits in the contralateral shoulder and arm
deviation of the head and eyes toward the side of the affected cerebral artery
central motor problems ranging from expressive aphasia to dyskinesiasMiddle Cerebral Arteryprimary and sensory motor cortices on the lateral surface of the cerebral hemisphere
sections of the internal capsule
parts of the inferior parietal and lateral temporal lobesfull sensory loss and weakness or paralysis of the face, arm and leg on the opposite side of the body
blindness in the opposite visual field
deviation of the head and eyes toward the side of the affected artery
if the dominant (usually left) MCA has been occluded, there can be global aphasia
if the non-dominant MCA is occluded, there can be contralateral neglect or unawareness of neurological deficitsVertebral Arterymedulla of the brainstemvertigo
nystagmus
ipsilateral ataxia
hypoglossal nerve dysfunctionBasilar Arteryascending and descending motor and sensory tracts
vestibular and cochlear nerves
reticular activating systembilateral sensory and motor deficits
combined cerebellar and cranial nerve problems
stupor or coma
hemiparesis with contralateral cranial nerve dysfunction Posterior Cerebral Arterythalamus
hippocampus
underside of temporal lobe
medial surface of occipital lobe
motor areas of the midbrainsensory loss of the entire contralateral body
third nerve palsy with hemiparesis, hemiplegia, ataxia or decreased LOC
movement disorders of one side of the body
visual loss, specifically homonymous hemianopia
APPENDIX B
Stroke Core Measurements Venous thromboembolism (VTE) prophylaxis within 48 hours of admission Discharged home on antithrombotic therapy if no contraindications Anticoagulation therapy provided for patients with atrial fibrillation/flutter unless contraindicated Thrombolytic therapy within appropriate time frame if patient meets criteria Antithrombotic therapy by the end of hospital day 2 if no contraindications Patient receives education about stroke including their personal modifiable risk factors, how to activate EMS for stroke symptoms, prescribed medications, stroke warning signs and symptoms and the need for follow-up after discharge Patient discharged on a statin medication if there are no contraindicationsPatient is assessed for rehabilitation needs
APPENDIX C
Disease-Specific Care Certification Manual Standards
Clinically Specific Requirements and Expectations for Primary Stroke Center CertificationProgram management
Delivering or facilitating clinical care
Supporting self-management
Clinical information management
Performance improvement and measurementUse a standardized method of delivering care based on the Brain Attack Coalitions Recommendations for Establishment of Primary Stroke Centers
Support patient self-management activities
Tailor treatment and intervention to individual needs
Promote the flow of patient information across settings and providers, while protecting patient rights, security and privacy
Analyze and use standardized performance measure data to continually improve treatment plans
Demonstrate their application of and compliance with clinical practice guidelines published by the AHA/ASA or equivalent evidence-based guidelines
APPENDIX D
Data Entry Items for Get With the Guidelines-Stroke databaseFinal clinical diagnosis related to stroke
ICD-9 principal diagnosis code
Earliest documentation of comfort measures only if applicable
Discharge disposition
If not discharged home, where was the person discharged
Patient location when stroke symptoms started
How patient arrived to hospital
Where did patient first receive care in the hospital
Was there advanced notification by EMS
Arrival date and time
Admit date
If patient was not admitted, reason for not admitting
Where was the patient admitted to in the hospital, by who, was there a stroke consult
Initial physician seeing the patient
Demographics: age, gender, ethnicity, health insurance status
Medical history pertaining to stroke risk factors
Ambulatory status prior to current event, at admission and at discharge
Symptom duration if presenting with TIA
Resolution of stroke symptoms at time of presentation?
NIH stroke scale: was it done and what was the score
Initial exam findings related to stroke symptoms
Current medication class if antiplatelet/anticoagulant, antihypertensive, diabetic medication, and cholesterol-reducer
Date and time patient last known to be well
Date and time of discovery of stroke symptoms
Date and time of brain imaging if done for this episode of care with results
Date and time IV tPA given if qualified
Documentation of contraindications if tPA not given
Was tPA given at another facility prior to transfer with date and time
Complications of tPA therapy
Was dysphagia screen done prior to giving the patient anything by mouth and results
Was the patient treated for hospital acquired pneumonia or DVT
Was DVT prophylaxis initiated by the end of day 2 and what type and when
Was the patient ambulating by the end of day 2
If DVT prophylaxis not initiated, is there proper documentation of the reason
Was antithrombotic therapy administered by the end of hospital day 2
Labs including lipid levels, PT/INR, creatinine, Hgb A1c and blood glucose
Vitals including admit and discharge BP and pulse, height, weight, waist circumference and BMI
Discharge date
Discharge medications including antithrombotics, antihypertensives, anticoagulants, diabetic meds and cholesterol reducing medications
Lifestyle interventions
Stroke education
Assessment for rehab services
APPENDIX E
Inclusion/Exclusion Criteria for IV tPA from www.strokecarenow.com
Patient Inclusion Criteria (must be YES to all)
Age 18 years or older
Clinical diagnosis of Ischemic Stroke
Measureable neurological deficit
Clearly defined time of stroke onset (within 180 minutes of stroke onset)
Informed consent (if possible)
May extend treatment window to 4.5 hours if patient does not meet additional exclusion criteria (see below)
Patient Exclusion Criteria (all must be NO before treatement)
Evidence of intracranial hemorrhage on pretreatment CT scan
Minor or rapidly improving symptoms
Symptoms of subarachnoid hemorrhage, even with normal head CT
Active internal bleeding: Gastrointestinal or urinary bleeding within last 21 days or known bleeding risk, including but not limited to:
a. Platelet count less than 100,000/mm3
b. Heparin during the preceding 48 hours associated with elevated
aPTT
Currently taking oral anticoagulants (e.g. Warfarin sodium) or
recent use with an elevated prothrombin time (PT) greater than
15 seconds or INR greater than 1.7
d. Major surgery or other serious trauma during preceding 14 days
e. Stroke, serious head trauma or intracranial surgery during
preceding 3 months
f. Recent arterial puncture at a non-compressible site
g. Recent lumbar puncture during preceding 7 days
Systolic BP greater than 185 mm of Hg or diastolic BP greater than 110 mm of Hg at the time of t-PA infusion and/or patient requires aggressive treatment to reduce blood pressure to within these limits
History of intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm
Recent Acute Myocardial Infarction
Observed seizure at stroke onset
Relative Contraindications
Early signs of a large cerebral infarction: edema, hypodensity, mass effect, and obliteration of sulci in more than 1/3 of middle cerebral artery territory on CT scan.
NIHSS greater than 22
Glucose less than 50 mg/dL or greater than 400 mg/dL.
Pregnant female
Difficult to control hypertension
Age greater than 75
Additional Exclusion Criteria for 4.5 hour window
Patient older than 80 years of age
Patient with a history of both diabetes AND stroke
Coumadin (warfarin) use regardless of INR
NIHSS greater than 25
A P P E N D I X F
D i a g n o s i s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e o f A s s e s s m e n t : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ T i m e : _ _ _ _ _ _ _ _ _
R e s p i r a t o r y s t a t u s : % T R A C H % V E N T % A b n o r m a l L u n g S o u n d s % A b n o r m a l C h e s t x - r a y
D i e t P r i o r t o A d m i s s i o n : % R e g u l a r % P u r e e d % T h i c k e n e d L i q u i d s % T u b e F e e d i n g
C o g n i t i v e S t a t u s : A l e r t - %Y e s %N o F o l l o w s C o m m a n d s : %Y e s %N o
T h e f o l l o w i n g i t e m s a r e i m p o r t a n t w a r n i n g s i g n s f o r p a t i e n t s w i t h p o s s i b l e d y s p h a g i a . P l e a s e i n d i c a t e b y p l a c i n g a c h e c k m a r k
b e d s i d e t h e a p p r o p r i a t e w a r n i n g s i g n if they are observed. The patient should be elevated to a 90 degree hip flexion angle prior to
completing the screen. Ensure the patient can maintain alertness for at least 10 minutes prior to completing this screen.
IF ONE OR MORE WARNING SIGNS ARE OBSERVED THE PATIENT WILL BE MADE NPO. OBTAIN A PHYSICIANS ORDER TO CONSULT SPEECH THERAPY. PAGE SPEECH THERAPIST ON CALL MONDAY THROUGH FRIDAY 0900-1700 SATURDAY 0800-1630, AND SUNDAY 0800-1200
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