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

2. 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.

3. 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

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

5. 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

6. 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.

7. 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)

8. 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?

9. 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.

10. 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

11. 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)

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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.

19. 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.

20. 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.

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

22. 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.

23. 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.

24. Stroke Treatment

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

26. Any Questions?

27. References http://www.ncbi.nlm.nih.gov/books/NBK2681/
Activase.com
Kallem, Crystal. "Analyzing Clinical Quality Measures for Meaningful Use." Journal of AHIMA 81, no.11 (November/December 2010):