Preparing for Stroke Certification use these colors Preparing for Stroke Certification Stroke Coordinator Boot Camp April 17, 2015

Presenter Disclosure Information MJ Hampel Preparing for Stroke Certification Financial Disclosure: No relevant financial relationship exists

Acute Stroke Ready Hospitals Models of Stroke Care Primary Stroke Center 1000 – 1200 Acute Stroke Ready Hospitals 1200 - 1800 Academic medical center, tertiary care facility CSC 75 – 200 2012 Wide range of hospitals; standard stroke care; stroke unit; uses tPA 2003 Rural hospitals; basic care; drip and ship; use tele-technologies July2015

Certified Stroke Centers By the Numbers PSC CSC TOTAL USA 1060 85 1145 Indiana 22 1 23 Illinois 54 5 59 Michigan 29 3 32 Nebraska 13 < Data as of 4/8/15 >

PSC vs. ASRH Primary Stroke Center Acute Stroke Ready Hospital Stabilize and provide emergency care for patients with acute stroke Designated beds for acute stroke patients Either admit or transfer to a CSC Acute Stroke Ready Hospital Provide emergency care for patients with acute stroke Does not have designated beds for stroke patients Drip and ship Use telemedicine technologies

Characteristics of an ASRH Small, rural Acute Care Hospital or Critical Access Hospital (~100 beds or less) No designated stroke beds Relationship with local EMS fostering communication from the field during transport and sharing educational opportunities Use of stroke protocols and an acute stroke team to expedite the assessment and treatment of a patient presenting with a stroke Teleconsult capability and transfer agreements with facilities that provide primary or comprehensive stroke services The ability to administer intravenous thrombolytics, if needed, prior to transferring the patient to a facility that provides primary or comprehensive stroke services As I mentioned earlier, ASRH candidates are rural hospitals, like most of you, with no designated stroke beds. A relationship with EMS is the key to rapid treatment for stroke patients therefore, communication, protocols and education between EMS and the ASRH are key components of the certification.

Advanced Certification Model Quality & Safety of Care for Patients Process Clinical Practice Guidelines Structure Standards + program specific requirements Outcome Standardized Performance Measures

Structure: ASRH Requirements Initial Assessment Telemedicine Transfer Protocol Staff Education Performance Measurement

ASRH Initial Assessment Performed by physician, nurse practitioner or physician assistant within 15 minutes of arrival Includes NIHSS, CT/MRI, blood glucose test and dysphagia screen (prior to oral intake) 24/7 access to Stroke expertise, including consultation for IV-thrombolytic therapy CT/MRI, lab tests, ECG, and chest x-ray WHEN ORDERED. Results available within 45 minutes (60 minutes for MRI)

ASRH Telemedicine Can provide informed consultation to ED practitioners, including evaluation of images Telemedicine/teleradiology equipment is onsite Telemedicine link is initiated within 20 minutes of when it is deemed necessary

ASRH Transfer Protocol(s) Agreement with one PSC or CSC Transfer IV-thrombolytic and neurosurgical patients Patients should leave the hospital within 2 hours of ED arrival or when medically stable Written protocol includes communication and feedback from receiving facility

ASRH Staff Education Members of core stroke team receive at least 4 hours of stroke education annually ED staff (not including physicians) participate in 2 stroke educational activities per year Makes educational opportunities available to prehospital personnel

ASRH Performance Measurement Monitor ability to administer t-PA within 60 minutes Monitor t-PA complications including symptomatic intracerebral hemorrhage and serious life-threatening systemic bleeding Committee meets twice a year to evaluate protocols and practice patterns

Additional Requirements for ASRH Topic Standard Number Relationship with EMS DSPR.3, EP 4 Stroke team log DSPM.3, EP 2a Stroke registry DSPM.3, EP 2b

Process: Clinical Practice Guidelines Current evidence-based guidelines are embedded in the ASRH standing orders. Evaluated thru patient tracer activity Most frequently-cited requirement for improvement: 31% of reviews in 2014 cited for not delivering care through the use of CPGs On-line resources: American Heart Assn at www.heart.org National Guideline Clearinghouse at www.guideline.gov

Outcome: Performance Measurement Criteria Four process or outcome measures to monitor on an ongoing basis Select from the universe of measures; or Create your own measures Two of the measures must be clinical Other two measures can be clinical, administrative, utilization, or satisfaction

ASRH Performance Measurement Potential choices include Door to needle time Turn around time for head CT/laboratory tests Practitioner response time to code stroke Patient complications Time to telemedicine link initiation Any of the stroke core measures Resource for measures: http://www.qualitymeasures.ahrq.gov/

Certification Logistics Pre Gap analysis to standards and guidelines; resolution of any gaps Apply 4-6 months before desired review date Data Collection Visit 30 days advance notification of date ASRH and PSC: One reviewer x one day CSC: Two reviewers x two days Post Data collection and submission Intracycle conference call 12 months after visit Apply for recertification Recertification visit occurs 2 years after initial visit To be scheduled within 90 day window around anniversary date 7 days advance notice of date

Benefits of Certification Builds the structure required for a systematic approach to clinical care Reduces variability and improves the quality of patient care Pushes you to look at yourself more closely Creates a loyal, cohesive clinical team Provides an objective assessment of clinical excellence Differentiates clinical care in the marketplace Promotes achievement to referral sources

Contact Information MJ Hampel, MPH, MBA Director, Clinical Services Certification The Joint Commission 630-792-5720 mhampel@jointcommission.org

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