Stroke Program Orientation for Nursing Beth Wiese, BSN, SCRN Stroke Program Coordinator St Charles Health System

Primary Stroke Center The St. Charles Health System has earned the Gold Seal of Approval and Primary Stroke Center certification from the Joint Commission. As an advanced primary stroke center, we follow a set of recommendations from the Brain Attack Coalition, a national group of medical, governmental, and professional associations dedicated to reducing the suffering caused by stroke.

The recommendations focus on 11 aspects of stroke care: 1.Acute stroke team: includes a doctor experienced in diagnosing and treating cerebrovascular disease, along with other specialists, available 24 hours a day, seven days a week to evaluate within 15 minutes any patient who may have suffered a stroke Beth Wiese, RN Stroke Coordinator, Dr. Steve Goins, Stroke Director 2.Written care protocols: written procedures to help streamline and speed up the diagnosis of stroke and treatment of stroke patients 3.Emergency medical services: in-the-field diagnosis and treatment, and rapid transport of patients to the emergency department 4.Emergency department: ED staff trained in diagnosing stroke and treating patients with stroke; maintaining strong lines of communication with EMS and the stroke care team 5.Stroke care team: a unit of hospital-based specialists called together to provide monitoring and care of stroke patients 6.Neurosurgical services: a specialty that focuses on the surgery that treats diseases of the brain, spinal cord and nervous system 7.Support of medical organization: the commitment of administration and professional and nonprofessional staff to provide high-quality care to stroke patients 8.Neuroimaging: imaging of the brain, spinal cord and nervous system, with the capability of performing an imaging study within 25 minutes of the doctor's order, and evaluating the image by a doctor within 20 minutes of its completion 9.Laboratory services: around-the-clock standard laboratory services, including chest x-rays and measurements of heart activity, with results delivered rapidly and accurately 10.Quality improvement: includes written or electronic recordkeeping for tracking the number and types of stroke patients seen, their treatments, and some measurement of patient outcomes 11.Educational programs: continuing medical training for the professional staff of a primary stroke center, and at least two programs a year to educate the public about stroke prevention and the availability of emergency treatment

Stroke Care What’s the best way to care for stroke patients? Are there guidelines for care of a stroke patients?

Stroke Care Guidelines: 2013 AHA/ASA Guidelines for the Early Management of Adults with Ischemic Stroke 2013 AHA/ASA Guidelines for the Management of SAH 2014 Revised and Updated Recommendations for the Establishment of Primary Stroke Centers National Guideline Clearinghouse-US Dept of Health and Human Services

Stroke Care The guidelines are the basis for protocols for treating the Acute Stroke Patient Drive the Quality care of stroke patients GWTG-Stroke helps healthcare facilities ensure continuous quality improvement of stroke treatment by aligning clinical care with evidence-based guidelines. AHA/ASA have partnered with Joint Commission for certification of Primary Stroke Centers. St. Charles Health System became a PSC in 2012.

Joint Commission Standardized Performance Measures for Stroke Venous Thromboembolism(VTE) Prophylaxis by Day 2 (Ischemic and Hemorrhagic) Discharged on Antithrombotic Therapy Anticoagulation Therapy for At Fib/Flutter Thrombolytic Therapy Antithrombotic Therapy by end of Hospital Day 2 Discharged on Statin Medication Dysphagia Screening Smoking Cessation Stroke Education (Ischemic and Hemorrhagic) Assessed for Rehab (Ischemic and Hemorrhagic)

Data Each measure needs to be analyzed and evaluated. Where does the information come from? What is done with it? Who is responsible for what? How is it coordinated?

Data Each stroke patients care is reviewed on an ongoing basis Analyzed according to the standardized performance measures Improve upon care ongoing rather than retrospectively. GWTG database can benchmark to other facilities.

Venous Thromboembolism Prophylaxis Thromboembolism is more common than we think PE accounts for approx 10% of deaths after stroke DVT and PE are more likely to occur in the first 3 months after stroke Methods to prevent include early mobilization, antithrombotic agents, and external compression devices If contraindicated may need Filter placement into the Inferior Vena Cava

Venous Thromboembolism Prophylaxis To meet the indicator: Must be administered the day of admission or by midnight the 2nd day Lovenox or heparin and/or compression devices acceptable If no VTE warranted (ex. Patient ambulatory or low risk of VTE) it needs to be documented in chart before midnight on the 2nd inpatient day Any reason for not meeting indicator needs to be documented in the chart (refusal, etc)

Discharged on Antithrombotic Therapy Imperative for stroke prevention There needs to be documentation in the chart that patient was given prescription for antithrombotic medication at discharge Acceptable medications include ASA, Aggrenox, Plavix, Ticlid, Lovenox, Coumadin Low dose anticoagulant to prevent DVT’s are insufficient as antithrombotic therapy to prevent recurrent strokes

Discharged on Antithrombotic Therapy Antiplatelet or Anticoagulant are acceptable If not prescribed, needs to be documented by the physician. Acceptable documentation: Allergic Refusal Risk for or actual bleeding Serious side effects Terminal illness, comfort measures only

Anticoagulation Therapy for Atrial Fib/Flutter A patient that has a documented episode of Atrial Fib this admission. Remote history doesn’t matter. If patient has Atrial Fib or Flutter must go home on anticoagulant if not, needs to be documented. Acceptable documentation Allergy Mental status Refusal Risk of or actual bleeding Risk for falls Serious side effects to medication Terminal illness/comfort measures only

Thrombolytic Therapy If patient arrives within 2 hours of symptom onset, they should receive thrombolytics within 3 hours. If Ischemic Stroke Patient does not receive IV tPA, a documented reason needs to be included in the patient chart. May use exclusion criteria in addition to: Advanced age Care team cannot determine eligibility Left heart thrombus Life expectancy <1 year NIHSS>22

Antithrombotic Therapy by end of Hospital Day 2 Must be administered by midnight of Day 2 Antiplatelet (ASA, Aggrenox, Plavix, Ticlid) or Anticoagulant (Heparin IV, Lovenox, Coumadin, or arixtra) Acceptable documented reasons for not meeting: Risk of bleeding Refusal Terminal illness Allergy Serious side effect of medication

Discharged on Statin Medication The patient should be discharged on cholesterol reducing medication as part of prevention Acceptable documented reasons for not prescribing a statin on discharge Allergy Refusal Arrhythmias Hepatitis Hypoglycemia Liver failure Rectal Hemorrhage Intracranial Hemorrhage Rhabdomyolosis

Stroke Education Required documentation for education Personal modifiable risk factors for stroke Stroke Warning Signs and Symptoms How to Activate EMS for Stroke Need for Follow up after Discharge Medication information Provide and review Red Stroke Education Folder and Document in Discharge Assessment. The DC assessment can be opened upon admission, Education should be provided day 1.

Dysphagia Screening All TIA’s, Hemorrhagic and Ischemic Strokes NPO until RN swallow screen complete. If swallow screen failed, patient is NPO until evaluated by SLP/ST. Document RN swallow screen in Daily Neuro Assesment upon admission, prior to initial PO intake and PRN. Patients who cannot tolerate PO intake should receive NG/ND or PEG tube feedings to maintain hydration and nutrition while undergoing efforts to restore swallowing.

Smoking Cessation Smoking Status documented upon admission. All St. Charles Health System patients who are documented smokers/tobacco users should have an order for Smoking Cessation Education. Cardiopulmonary Rehab provides education to all documented smokers. Additional education available through document library. Document education on daily assessment education tab.

Assessed for Rehab Assessment must be completed by any one member of the Rehab team including: Physiatrist Physical Therapist Occupational Therapist Speech Therapist

Data Reports Once all the data is retrieved, entered into system, generates a report…now what?? Look at indicators that are not improving, how can we fix it? Break it down, piece by piece.

Analysis Data is reviewed monthly, presented quarterly to the Stroke Committee. Protocols updated yearly and PRN. Order sets updated yearly and PRN. Data extraction, input and analysis done by Stroke Coordinator, audited by Relief Coordinator.

Stroke Treatment

New Stroke like Symptoms…think FAST Call x5555 from any hospital phone for a Rapid Response Team.

Any Questions?

References http://www.ncbi.nlm.nih.gov/books/NBK2681/ http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures/ https://qi.outcome.com/ http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelinesHFStroke/Get-With-The-Guidelines-Stroke-Home-Page_UCM_306098_SubHomePage.jsp Activase.com https://www.cms.gov/EHRIncentivePrograms/Downloads/MU_Stage1_ReqOverview.pdf http://thomsonreuters.com/content/healthcare/pdf/collateral/clin_perform_improvement_0211 Kallem, Crystal. "Analyzing Clinical Quality Measures for Meaningful Use." Journal of AHIMA 81, no.11 (November/December 2010): 56-59.