 Jenny Edwards, MSN, RN, CNRN, SCRN  Martha Power FNP, SCRN

 Every year 795,000 people in the United States have a stroke  1 of 4 die  87% of the strokes are ischemic, 13% are hemorrhagic  Over 1000 Certified Stroke Centers in the US  Half of the population of the United States lives more than 60 minutes from a Primary or Comprehensive Stroke Center

 Improves quality of care by reducing variation in clinical processes.  Provides a framework for program structure and management.  Objective assessment of clinical excellence  Facilitates marketing, contracting and reimbursement  Strengthens community confidence in your care

 Stroke Ready 0  PSC >1000  CSC 93  Stroke Ready 0  PSC 90  CSC 25  Stroke Ready 0  PSC 41  CSC 0  Stroke Ready 0  PSC 3

 Developed in Collaboration with AHA/ASA  Applications accepted starting 7/1/15  Derived from the BAC Rec 2013 “Formation and Function of Acute Stroke Ready Hospitals within a Stroke System of Care” in Nov 12, 2013 Stroke journal  Goal: to recognize hospitals equipped to treat stroke patients with timely, evidenced-based care prior to transferring them to a PSC or CSC  2yr certification after an onsite review

 “An Acute Stroke Ready Hospital will be the foundation for acute stroke care in many communities, allowing it to be the first stop on a patient’s acute stroke journey before being transferred to a Primary Stroke Center or Comprehensive Stroke Center. Certification demonstrates a commitment to a higher standard of service, while promoting the best quality care for all patients that present with a stroke.” Wendi Roberts Executive Director, Certification Programs, TJC namerican_stroke_association_launch_new_stroke_certification_program/

 Dedicated Stroke Focused Program  Collaboration with EMS – encourage training in assessment tools and prenotification of arrival  24/7 rapid diagnostic and laboratory tests  Availability of telemedicine technology  Ability to give IV thrombolytics to eligible patients.  Transfer agreements/protocols with facilities that provide PSC and CSC services

 In order for a hospital to be eligible for ASRH certification, an organization should see its role in stroke management as administering intravenous thrombolytics and then transferring patients to a primary or comprehensive stroke center (or center of comparable capability) for continued treatment.  There must be transfer protocols in place indicating that transfer after thrombolytics is the planned pathway for the vast majority of patients (unless the patient is unstable or not a candidate for advanced therapies).

 Protocols to address the prompt diagnosis and emergency treatment of stroke patients  One Physician, NP or PA onsite to supervise patient care, order medication and manage emergent issues  Educational Requirements  Data Collection and Process Improvement  Free 90 day access of Standards at

 The program maintains a stroke log that includes at a minimum: 1. Number of times stroke team was activated 2. Practitioner response time to acute stroke patients 3. Type(s) of diagnostic tests and acute treatment if used 4. Patient diagnosis 5. Door-to-IV thrombolytic time 6. Patient complications 7. Disposition of the patient (for example, upon admission to the organization, discharge, transfer to another organization)  The program utilizes a stroke registry or similar data collection tool to monitor the data and measure outcomes.  The program monitors its IV thrombolytic complications, which include symptomatic intracerebral hemorrhage

 Follows recommendations published by the Brain Attack Coalition and the American Stroke Association consensus statements for stroke  Evaluates compliance with national standards, clinical practice guidelines to manage and optimize care, and the institution’s performance improvement  Any hospital (even small, rural) can be designated a PSC  Willing and able to give IV tPA  Systematic approach to QI and patient education  If a hospital performs intra-arterial (IA) or endovascular procedures for stroke patients, the minimum level of Joint Commission certification for which the hospital is eligible is PSC certification

 Administrative support is key!  Administrative lines of authority  Organizational chart for Stroke Center  Medical Director appointed  Physicians with expertise in cerebrovascular disease

 Written protocols ◦ Describing/defining the team  Specification of qualifications, education requirements, assignments of duties ◦ Notification process  Expected response times  Stroke team log  Performance Improvement process

Protocols based on published guidelines and updated regularly Acute work up of ischemic/ hemorrhagic stroke available in the ED, patient care areas Readiness evident no matter how or where individual enters the system tPA protocols – stick to the guidelines Use of protocol reflected in order sets, pathways, medical records Time parameters in ED

 Improved coordination between hospitals and EMS is a cornerstone of a Primary Stroke Center  Effective communications between EMS personnel and the stroke center during rapid transport  Stroke is recognized as a priority

◦ Definition: a specific unit where most stroke patients are admitted ◦ Care providers show evidence of initial and ongoing education in care of stroke patients ◦ Receive at least 8 hours annually of continuing education as appropriate to their responsibility ◦ Monitoring systems  Telemetry  Noninvasive blood pressure  Oximetry

 Some hospitals may choose to stabilize patients and transfer them to another facility  Provides care (ICU or stroke designated area)  Written care protocols (pathways/orders)  Use evidence based guidelines

 Protocols ◦ Increase use of t-PA  11% – 13% have excellent outcome at 90 days  48% likelihood of being discharged to home compared to 38% not receiving ◦ Utilizing clinical guidelines – organizes care and decreases complications  Stroke Units ◦ 17% reduction in death ◦ 7% increase in being able to live at home ◦ 8% reduction in LOS

◦ Available within two hours of when the services are deemed necessary  Fully functioning OR and staff for neurosurgery available 24/7  Call schedule available to stroke team ◦ Written transfer plan and protocol in place if patients are to be transferred to another facility for these services

◦ Specific stroke performance measurement and review by QI department and stroke team  PI measures tracked  Documentation of interventions to improve  Outcomes to determine success  Implementation period and re-evaluation point

 Stroke registry: clinical/financial  Public education  Primary and secondary prevention  Professional education  Clinical research

 With guidance of the Brain Attack Coalition, TJC has developed advanced certification for CSCs ◦ Hospitals with specific abilities to receive and treat the most complex stroke cases  The goal of CSC: ◦ To recognize the significant differences in resources, staff and training that are necessary for the treatment of complex stroke cases

◦ Personnel with specific areas of expertise ◦ Specialized diagnostic and treatment techniques ◦ Facility Infrastructure ◦ Programmatic Areas

 Center Director  Neurologists; Neurosurgeons; Intensivists  Surgeons with expertise in CEA  Diagnostic Radiologists  Interventional endovascular neuroradiology  ED and links to EMS  Radiology technologists  Nursing staff trained in acute stroke care  APNs  Physicians and therapists trained in rehab  Case managers; social workers

 Patients need accurate imaging of brain and cerebrovasculature (same as for PSC, plus): ◦ MRI/MRA ◦ DSA ◦ TCD ◦ TTE/TEE

 EMS, ED, Referral, Triage ◦ Rapid, efficient patient assessment and triage ◦ Pre-hospital communication with hospital staff ◦ Medical stabilization en route ◦ Support education  evidence of cooperative educational activities 2x/year ◦ ED protocols  Stroke team notification  Door to treatment ◦ CSC should be viewed as community and regional resource

 Stroke Unit and ICU ◦ Dedicated neurointensive care unit ◦ Rehab and post-stroke care  Education ◦ Professional  > 2 educational courses per year for health care professionals ◦ Public  Sponsor at least 2 educational activities per year that focuses on some aspect of stroke  Stroke risk factors, health fairs, etc

 Stroke Registry/Database ◦ LOS; treatment rate; discharge destination & status  Quality Assurance and improvement ◦ Peer review process to evaluate/monitor care  Patient-centered research approved by IRB  Coordinate post-hospital care for patients ◦ Stroke clinic

Systems of Stroke Care  1. Patients should be transported rapidly to the closest available certified primary stroke center or comprehensive stroke center or, if no such centers exist, the most appropriate institution that provides emergency stroke care as described in the 2013 guidelines (Class I; Level of Evidence A). In some instances, this may involve air medical transport and hospital bypass. (Unchanged from the 2013 guideline)  2. Regional systems of stroke care should be developed. These should consist of consisting of:  (a) Healthcare facilities that provide initial emergency care including administration of intravenous r-tPA, including primary stroke centers, comprehensive stroke centers, and other facilities.  (b) Centers capable of performing endovascular stroke treatment with comprehensive periprocedural care, including comprehensive stroke centers and other healthcare facilities, to which rapid transport can be arranged when appropriate (Class I; Level of Evidence A). (Revised from the 2013 guideline)