1. 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

2. 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
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3. Disclosures
No disclosures or conflicts of interest
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4. 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 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
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5. 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
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6. 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.
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7. Care Across the Continuum

8. 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

9. Indiana University Health Methodist Hospital Stroke Team
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10. 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

11. 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

12. 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
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13. 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

14. 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

15. 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 day follow up
Research
Peer review

16. CSC Survey Visit
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17. Performance Measures
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18. Questions What benchmarks are you using Current challenges
Process for multiple stroke alert patients
Patient family assessments
Cognition/ Respite/ transition of care communication

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

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

21. 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)

22. 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!

23. Identify Barriers Internal External Conflicting priorities
Limited resources

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