Alice Liskay, RN, BSN, MPA, CCRC Ohio Coverdell, Coordinator Mock Stroke Code Alice Liskay, RN, BSN, MPA, CCRC Ohio Coverdell, Coordinator

Objectives Describe a “mock stroke code.” List 2008-2009 patient safety goals. Implement a mock stroke code in their hospital utilizing tools provided.

What is a “Mock Stroke Code” ? Opportunity to: Improve care of patients with stroke Access staff knowledge and educate regarding current stroke protocols and guidelines Prepare staff for PSC Certification Site Visit Review staff knowledge of 2008 National Patient Safety Goals and revisions for 2009 Plan strategies for improvement as needed

Joint Commission NPSG and Requirements The National Patient Safety Goals (NPSG) promote specific improvements in patient safety by providing health care organizations with evidence-based guidance on persistent patient safety problems. Compliance with the requirement is a condition of continuing accreditation or certification for Joint Commission-accredited and –certified organizations. The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

New numbering New numbering for NPSG (part of the JC’S Standard Improvement Initiative Allows electronic sorting and addition of new requirements Six digit no. “NPSG.01.01.01” “Implementation Expectations” are now called “Elements of Performance” The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 1: Improve the accuracy of patient identification NPSG 01.01.01 - Use at least two patient identifiers when providing care, treatment, or services Elements of Performance: Involve patient and family as needed Two identifiers before administering meds Two identifiers before drawing blood Label blood in presence of patient The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 1: Improve the accuracy of patient identification NPSG 01.01.01 PSC Considerations: How do you identify patients with aphasia Drawing labs Administering tPA

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.01.01- For verbal or telephone orders or telephone reporting for critical test results, the individual giving the order or test result verifies the complete order or test result by having the person receiving the information record and “read back” the complete order or test result. The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.01.01: Elements of Performance: Those receiving the information writes down the complete order/test result or enters in computer Reads back order/test result Individual who gave order/result confirms the read back The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.01.01 PSC Considerations: Verbal orders for tPA Critical lab results (may be asked to see process) Orders- (may be checked to insure these are later signed-off by MD) What is your protocol for having orders signed-off?

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.02.01 – There is a standardized list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.02.01 – Elements of Performance: Organization develops standardized list Refer to TJC list of those not to be used “Do not use” list added to orders that are handwritten or entered as free text in computer Compliance also on preprinted orders PSC considerations: Charts are checked for this during tracer The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.03.01 – The organization measures, assesses, and, if needed, takes action to improve the timeliness of receipt of critical tests and critical results and values by the responsible licensed caregiver. The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.03.01 Elements of Performance: Defines critical tests and critical results and values Defines acceptable length of time for reporting of routine tests with critical abnormal values Defines the length of time of availability of results and receipt by responsible licensed caregiver Collects data of timeliness Assesses data and determines if PI is needed The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.03.01 PSC Considerations: CT order to done- 25 min CT order to report to MD- 45 min Lab order to result- 45 min ECG- order to result- 45 min How are these reported? Are they discussed in Stroke Committee? Is Process Improvement needed?

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.05.01 – The organization implements a standardized approach to hand-off communication, including an opportunity to ask and respond to questions. Includes, but not limited to: Shift changes; transfer to another unit or facility; on-call responsibility; meal coverage; critical results sent to MD offices The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.05.01 – Elements of Performance: Interactive communication that allows questions between giver and receiver Up-to-date information regarding condition, care, treatment, meds, services, and anticipated changes Method to verify received information, including read back techniques The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.05.01 – Elements of Performance Con’t: Opportunity for receiver to review relevant patient historical data, which may include previous care, treatment or services Interruptions during hand-off are limited to minimize errors The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.05.01 PSC Considerations: Hand-off for tPA patients between ED and MICU Where in process of VS assessment Results of dysphagia screen Will need to chart results Complications from tPA

Goal 2: Improve effectiveness of communication among caregivers NPSG. 02.05.01 PSC Considerations: Hand-off for stroke MICU and medical unit Results of dysphagia screen Does it need to be re-assessed Diet Need for Modified Barium Swallow Ambulatory status –DVD prophylaxis Day 2 Antithrombotics – Day 2 Medication reconciliation

Goal 7: Reduce the risk of health care associated infections NPSG.07.01.01- Reduce the risk of health care associated infections Elements of Performance: The organization complies with the World Health Organization or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Organizations are required to comply with 1A, 1B, 1C of the WHO or CDC guidelines.

Elements of Performance: Goal 8: Accurately and completely reconcile medications across the continuum of care NPSG.08.01.01 – A process exists for comparing the patient’s current medications with those ordered while under the care of your organization. Elements of Performance: At admission, a complete list of meds the patient is taking at home (including dose, route and frequency) is created and documented. Patient and family as needed involved in process. The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Elements of Performance Con’t: Goal 8: Accurately and completely reconcile medications across the continuum of care NPSG.08.01.01 – Elements of Performance Con’t: Medications ordered are compared to pre-admission list Any discrepancies are reconciled and documented When transferred within the organization, the current provider informs the receiving provider about the up-to-date medication list and document The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 8: Accurately and completely reconcile medications across the continuum of care PSC Considerations: Attention to: Antithrombotics Antiplatelets Anticoagulants Cholesterol lowering (Statins) Anti-hypertensives, DM Were they taken within the last week?

Goal 8: Accurately and completely reconcile medications across the continuum of care Pre-admission meds: Some elements that may be captured in the reconciliation form to help with the transitions of care Different times of day OTC medications Non-oral medications Dosage Indication Length of therapy Medication prescribed by different MD Allergies Compliance

Goal 8: Accurately and completely reconcile medications across the continuum of care NPSG.08.02.01 – When a patient is transferred from one organization to another, the complete and reconciled list of medications is communicated to the next provider of service and documented. When a patient leaves the organization’s care directly to home, the list is provided to the patient’s known PCP, or the original referring provider, or a known next provider of service. The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Elements of Performance: Goal 8: Accurately and completely reconcile medications across the continuum of care NPSG.08.02.01 Elements of Performance: Most recent reconciled medication list is communicated to the next provider of service, either within or outside the organization. Communication must be documented. Transferring organization informs next provider how to obtain clarification The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 8: Accurately and completely reconcile medications across the continuum of care NPSG.08.02.01 PSC Considerations: Consider your processes for “Drip and Ship” Consider your processes for IA patients Who is responsible for making sure meds are reconciled? How is medication information communicated to the next provider? In hospital system Not a network hospital

PSC Considerations con’t: Goal 8: Accurately and completely reconcile medications across the continuum of care PSC Considerations con’t: Do you provide a guide for medication and food interactions at discharge? Do you call outside pharmacy to verify meds if meds not typically filled at your institution? Do you have Pharmacist on your units to contribute to discharge planning?

Elements of Performance: Goal 8: Accurately and completely reconcile medications across the continuum of care NPSG.08.03.01 (New 2009) when a patient leaves the organization a complete and reconciled list of medications is provided directly to the patient, and patient’s family as needed, and the list is explained to the patient and/or family. Elements of Performance: Patient and/or family reminded to discard old lists and update records with PCP and Pharmacist The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 8: Accurately and completely reconcile medications across the continuum of care NPSG.08.04.01- (New 2009) In setting where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed. There is a caveat for some settings not needing dose, route and frequency. The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 8: Accurately and completely reconcile medications across the continuum of care NPSG.08.04.01- Elements of Performance: List of current medications and allergies to prescribe setting-specific meds and assess for allergic reaction and adverse reactions Short-term medication list. Not considered part of original list. If patient confused need to give both lists. New reconciliation list given to patient if new long-term medication is added or a change in their current meds. Standard reconciliation process if patient is going to be admitted to your organization The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

NPSG.08.04.01- PSC Considerations: Goal 8: Accurately and completely reconcile medications across the continuum of care NPSG.08.04.01- PSC Considerations: ED admission to floor ED discharges (if TIA with outpatient follow-up to PCP)

Goal 9: Reduce the risk of patient harm resulting from falls NPSG.09.02.01 – The organization implements a fall reduction program that includes an evaluation of the effectiveness of the program. Elements of Performance: Establishes a fall reduction program Program includes evaluation appropriate to the patient population, settings and services provided Includes interventions to reduce fall risk factors The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 9: Reduce the risk of patient harm resulting from falls NPSG.09.02.01 – Elements of Performance Con’t: Staff receive education and training Educate patient and/or their family and any individualized fall risk strategies Evaluates the fall program to determine effectiveness. Outcome indicators can be used: Decreased number of falls Severity of fall-related injuries The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 9: Reduce the risk of patient harm resulting from falls NPSG.09.02.01 – PSC Considerations: Fall risk specific for patients with stroke Impulsiveness Patient’s with SCDs Confused patient Leg weakness Patient with neglect Be ready to explain your falls program

Elements of Performance: Goal 10: Reduce the risk of influenza and pneumococcal disease in institutionalized older adults NPSG.10.01.01- The organization develops and implements protocols for the administration of flu vaccine Elements of Performance: Protocol to determine whether or not to administer flu vaccine Protocol implemented for patients identified as high risk for influenza The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Elements of Performance: Goal 10: Reduce the risk of influenza and pneumococcal disease in institutionalized older adults NPSG.10.02.01- The organization develops and implements protocols for the administration of pneumococcus vaccine. Elements of Performance: Protocol to determine whether or not to administer pneumococcus vaccine Protocol implemented for patients identified as high risk for pneumococcus The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Elements of Performance: Goal 10: Reduce the risk of influenza and pneumococcal disease in institutionalized older adults NPSG.10.03.01- The organization develops and implements protocols to identify new cases of influenza and to manage outbreaks. Elements of Performance: Protocol to identify new cases and manage outbreaks Protocol implemented to display signs and symptoms of influenza The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 13: Encourage patient’s active involvement in their own care as a patient safety strategy. NPSG.13.01.01- Identify the ways in which the patient and family can report concerns about safety and encourage them to do so. Elements of Performance: Educated on available Reporting methods for their concerns regarding care, treatment, services and patient safety issues The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Elements of Performance: Goal 13: Encourage patient’s active involvement in their own care as a patient safety strategy. NPSG13.01.01 Elements of Performance: Provide information regarding infection control measures for hand and respiratory hygiene and contact precautions according to their condition on the day the patient enters the organization (can be any media). Their understanding is evaluated and documented Encourage reporting of concerns The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Goal 13: Encourage patient’s active involvement in their own care as a patient safety strategy. NPSG13.01.01 PSC Considerations: Impulsive or Confused patient Leg weakness - falls Patient with neglect Aphasic patient Need for Dysphagia Screen

Universal Protocol UP.01.01.01- Conduct a pre-procedure verification process All relevant documents and related information or equipment are: Available prior to the start of the procedure Correctly identified, labeled, and matched to the patient’s identifiers Reviewed and are consistent with the patient’s expectations and with the team’s understanding of the intended patient, procedure and site The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Universal Protocol PSC considerations: UP.01.01.01 tPA checklist to cover essentials Consent /family permission/awareness Transfer of patient to CT scanner and/or angio suite Radiology and lab results are available

Universal Protocol UP.01.02.01- Mark the procedure site. Procedure site is marked by licensed independent practitioner who is privileged to perform the intended surgical or non-surgical invasive procedure. The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Universal Protocol UP.01.03.01- A time-out is performed immediately prior to starting procedure. Final assessment that correct patient, site, position, procedure are identified and all relevant documents, related information and necessary equipment are available. Elements of Performance: Time –out characteristics: Standardized Initiated by a designated member of the team Involves immediate members of the procedure team Involves interactive verbal communication Defined process for reconciling differences The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Universal Protocols UP.01.03.01 Elements of Performance con’t: During time-out, other activities are suspended to the extent possible. If two procedures are being performed on the same patient, a time-out needed for each. Time-out address: correct patient; correct site is marked; consent form; agreement of procedure; position; relevant images and results properly labeled and displayed; the need for antibiotics or fluid as needed; safety precautions based on history or medication. The completed components of the Universal Protocol and time-out are clearly documented. The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

Universal Protocols UP.01.03.01 PSC considerations Time-out before starting IV and IA tPA