Comprehensive Stroke Center Certification Stroke Boot Camp Georgann Adams RN, MSN,ACNS-BC CNRN, SCRN, CCRN Stroke Program Coordinator, IU Health Methodist Hospital 9/17/2018

Objectives Discuss the requirements of The Joint Commission’s Comprehensive Stroke Center Certification (CSC) Discuss components of the onsite visit that are unique to a CSC 9/17/2018

Disclosures No disclosures or conflicts of interest 9/17/2018

Comprehensive statewide healthcare system with 18 hospitals in Indiana IUH Methodist was the first to become certified in Indiana as a Joint Commission Comprehensive Stroke Center in 2014 treating over 800 complex stroke patients a year. In addition to the CSC we have 3 other Primary Stroke Centers in the system and hoping to add another in 2015 9/17/2018 4

Approximately 85 centers that are currently certified Revised standards in July 2014 Started reporting 8 CSC measures in Jan 2015 Definition of a CSC A facility or system with the necessary personnel infrastructure expertise With programs to diagnose and treat stroke patients Who require a high intensity of medical and surgical care, specialized tests, or interventional therapies 9/17/2018

A Comprehensive Stroke Center Act as a resource center for other facilities in their region providing expertise about managing particular cases offering guidance for triage of patients making diagnostic tests or treatments available to patients treated initially at a PSC an educational resource for other hospitals and health care professionals in a city or region. 9/17/2018

Care Across the Continuum

Written care protocols Dedicated Stroke Units Acute Stroke Treatment Team with 24/7/365 activation and rapid emergency response Relationship/support of Emergency medicine and pre-hospital paramedic community Interventional Neuroradiology part of stroke team Written care protocols Acute management Secondary Prevention Rehabilitation Risk Factor modification Dedicated Stroke Units Access to neurosurgical services 24/7/365 STAT access to neuroimaging and laboratory services 24/7/365 Demonstrated support of the medical organization Stroke Registry supporting quality management Team and staff education Community education program/marketing

Indiana University Health Methodist Hospital Stroke Team 9/17/2018

Stroke Team Committee People Departments MD’s ED ED Radiology Neurologists Neurosurgeons Interventional Neuro Radiologists Internal Medicine RN’s MSW Technologists Rehabilitation Therapists OT/PT/SLP Departments ED Radiology Case Management Administration Nursing Research Clinical Education Rehabilitation

CSC Survey Pre survey conference call Eligibility requirements “CSC Requirements Assessed at Application” DSPM volume requirements DSPR Advanced Imaging Capabilities DSDF 5,6 DSSE 1,3 Post hospital Care coordination DSPR Dedicated neuro-intensive care beds for complex strokes DSPR 5 Research and written research protocol DSPR Interdisciplinary program level review and peer review DSPM Performance measures Onsite agenda CSC reviewer are highly trained and may include a stroke neurologist

Meets disease specific care requirements ( PSC) Volumes 20 SAH 15 aneurysmal clippings ablations/ year 25 rtPA administrations to eligible acute ischemic stroke patients/in 2 year Advanced imaging capacity 24/7 ( MRI,MRA, CTA, transcranial doppler, TEE, ) After hospital care coordination Peer review mechanism Participation in IRB, patient–centered stroke research Collection of 8 comprehensive standard performance measures At one point TJC moved to 35 or more patients per year with a diagnosis of subarachnoid hemorrhage caused by an aneurysm. Note: Caring for 105 subarachnoid hemorrhage patients over a three-year period is acceptable. b. 10 microsurgical clippings per year. Note: Performing 30 microsurgical clippings over a three year period is acceptable c. 20 endovascular coiling procedures per year. Note: Performing 60 endovascular coiling procedures over a three-year period is acceptable 9/17/2018

2014 Volumes Ischemic Stroke: 479 Subarachnoid Hemorrhage (SAH): 133 CSC Requirement: Care is provided to 20 SAH or more per year Intracerebral Hemorrhage (ICH): 127 Carotid Endarterectomy (CEA): 131 At one point TJC moved to 35 or more patients per year with a diagnosis of subarachnoid hemorrhage caused by an aneurysm. Note: Caring for 105 subarachnoid hemorrhage patients over a three-year period is acceptable. b. 10 microsurgical clippings per year. Note: Performing 30 microsurgical clippings over a three year period is acceptable c. 20 endovascular coiling procedures per year. Note: Performing 60 endovascular coiling procedures over a three-year period is acceptable 9/17/2018

2014 Treatment Volumes Treatment for Aneurysm: 130 CSC Requirement: 15 or more coils or clips per year Coiling: 84 Clipping:46 IR for ischemic stroke: 24 IV tPA: 89 CSC Requirement: Administer IV tPA to 25 pts per year EMTC: 55 In-house: 7 Drip & Ship: 27

Agenda Template Develop and opening and ed presentations, Day 2 Daily briefing Individual tracer review Similar to day 1 System tracer- Data use, research, PI. Conducted by both reviewer PI methodology Volumes of procedures and intervention Clipping and coiling mortality rates Complication rates Public reporting Stroke performance measures Follow up phone calls Interdisciplinary program review and peer review process use of stroke registry Patient satisfaction CSC research Review of stroke log Education, competence assessment and Credentialing process Review of personnel files Community education Issues resolution Exit conference Opening conference and orientation to the program Emergency Department review – 2 reviewers Individual tracers reviewers conduct separately ( morning and afternoon sessions) Advanced imaging Acute comprehensive stroke care Emergency care Informed consent Preop evaluation IR suite CT/ MRI Procedures and intervention ICU care Medical Care Nursing Care Post Acute Care Social work Therapy( speech, OT, PT) Transfer/ Discharge Follow up call Closed record review Summary session at end of first day Address any special issues for resolution Develop and opening and ed presentations, consider a mobile command post Assemble and organize key sources of information Onsite tracers CPG orders documentation use of emr, transitions, team assessments turn around times System tracers PSC Surgical outcomes CEA/CAS standard of care assurance Readmissions 30- 90 day follow up Research Peer review

CSC Survey Visit 9/17/2018

Performance Measures 9/17/2018

Questions What benchmarks are you using Current challenges Process for multiple stroke alert patients Patient family assessments Cognition/ Respite/ transition of care communication

Competence Tracers Physician and APN Credentialing and privileging Education requirements Clinical Services and Allied Health Expanded to imaging areas Rehab staff and RRT

Education Medical directors/ Physicians Emergency Department Neuro ICU Stroke Units Interventional Radiology Stroke Team RRT Other departments and support staff

Helpful Hints Review active inpatient census Encourage additional staff Request team availability IT staff experts Identify strong escorts and communication across the system Team meetings and prep with champions Review institutional initiatives and review weak areas (individual care plans, education, falls)

Core team drive the process Everyone needs to be able to describe how we provide care, algorithms, outcomes and availability of experts Continuous Journey Attend national, local and web education offerings and meetings to network and continuously learn!

Identify Barriers Internal External Conflicting priorities Limited resources

Group Dedication Engaged leaders Physicians Administrator Clinical nursing staff Rehabilitation Pharmacy Research Quality