1. ENHANCING YOUR SKILLS IN STROKE QUALITY IMPROVEMENT AND DATA ANALYSIS
Sherry Mosier, BSN, RN, CNRN, SCRN
Lynn Wilton, MS RN, CRRN, CNRN

2. DISCLOSURES
Sherry Mosier has no actual or potential conflict of interest in relation to this presentation
Lynn Wilton has no actual or potential conflict of interest in relation to this presentation

3. Methodist Hospitals, Gary/Merrillvillle
Two campus hospital system
Methodist Hospital Northlake
Methodist Hospital Southlake
Inpatient Beds
Total beds 634, split between the 2 campuses
Total Adult Beds 504
Physicians
581 Active / Associate 389

4. Stroke Care at Methodist Hospitals
Each campus has been Primary Stroke Certified (PSC) by Healthcare Facilities Accreditation Program (HFAP) since 2010
Two full time neurologists
One neurointerventional radiologist
One stroke coordinator
Stroke coordinator consults per month, 70 – 80
Stroke discharges per year
350 – 400

5. Parkview Health System: Allen County Campuses
Parkview Regional Medical Center
Parkview Randallia
451 bed Level II Trauma Center
154 bed Community Hospital
Parkview Health System: Allen County Campuses

6. Joint Commission Primary Stroke Center under a single license: Over 900 stroke discharges in 2014

7. Parkview Health System:
LaGrange
Huntington
Whitley
Noble
Parkview Health System:
Community Hospitals
152 beds

9. Discussion Points: Quality Guidelines The data itself Target stroke
Reporting
Core Measures

10. Quality
According to the Institute of Medicine it is defined as “the extent to which health services provided to individuals and patient populations improve desired outcomes. The care should be based on the strongest clinical evidence and provided in a technically and culturally competent manner with good communication and shared decision making.”

11. Quality Improvement Key word is improvement Analysis of performance
Systematic ways to improve it
Goal is for best outcome
CHECK

12. Guidelines
Clinical practice guidelines are recommendations about patient care with special conditions based on the best available research evidence and practice experience
Stroke care quality protocols are based on:
Brain Attack Coalition
American Heart Association
GWTG-Stroke helps facilities ensure continuous improvement of stroke treatment by aligning clinical care with evidence based guidelines

14. Data
“The appropriate source of data for quality assessment depends on the purpose for which the information will be used.” (NIH)
Utilize stroke database or registry (ie, GWTG or Coverdell)
Each measure needs to be evaluated and analyzed
Questions to ask:
Where does the information come from?
How is it coordinated?
Who is responsible?
What is done with the data?
Analyzed according to standardized performance measures
Review on a regular basis
Benchmark externally

15. Enhancing Quality Processes
Stroke Inservice/Education
Physician and nursing educational opportunities
Peer review
Stroke champions
Chart review
Committees

16. Internal and External Reporting
Quarterly submissions
Joint Commission
HFAP
DNV
State
CMS
Internal Reporting
Integration with hospital PI process
Leadership performance improvement
Physician performance improvement
Nursing performance improvement
Stroke Committee
Other stroke care providers (ED, units, EMS, non-stroke units, radiology, IR, cardiopulmonary)

17. Core Measures
Evidence-based, scientifically-researched standard of care which has been shown to result in improved clinical outcomes
Utilizes results of evidence based medicine research
Basic core measure principles imply that it is reasonable to expect that every patient with a given diagnosis will receive the baseline (core) care established through research

18. Importance Appropriate Core Measure care is:
Right care every time
Reduced morbidity, mortality, complications and readmissions
It is evidence-based best care for your patients!

19. Quality is more than just numbers, it is people working together:
Data base specialist: Diana Rupley – Activate data base, GWTG
Quality specialists: Tanya Freon and Amber Schiebel
Midas Quality Manager: Petra Smith
SCNN coordinator: Brandy Fey
Nursing
Neurologists/Neuro-interventionalist
ED physicians

20. HFAP SM
Measure/Indicator
SM-1
Stroke Team Arrival (minutes)
SM-2
Laboratory Studies (minutes)
SM-3
Neuroimaging Studies (minutes)
SM-4
Neuro-Surgical Services (minutes)
SM-5
tPA Administration (0 - 3 hrs)
SM-6
Antithrombotic Therapy (%)
SM-7
Antithrombotic at Discharge (%)
SM-8
Anticoagulant at Discharge (%)
SM-9
DVT Prophylaxis (%)
SM-10
Statin at Discharge (%)
SM-11
Stroke Education
SM-12
Dysphagia Screening (%)
SM-13
Physical Rehab Evaluation (%)
SM-14
Door-to-Needle Time (minutes)
JC PM
 Measure/Indicator
STK - 1
Venous Thromboembolism (VTE) Prophylaxis
STK - 2
Discharged on Antithrombotic Therapy
STK - 3
Anticoagulation Therapy for Atrial Fibrillation/Flutter
STK - 4
Thrombolytic Therapy
STK - 5
Antithrombotic Therapy By End of Hospital Day 2
STK - 6
Discharged on Statin Medication
STK - 8
Stroke Education
STK - 10
Assessed for Rehabilitation

21. Target Stroke Launched 2010
A national quality improvement initiative focused on improving acute ischemic stroke care by reducing door-to-needle times for eligible patients being treated with tPA

22. Target Stroke Phase II 2014: Improvement Strategies
EMS pre-notification
Rapid triage protocol and Stroke Team notification
Direct transfer to CT/MRI
Single call activation system
Rapid acquisition and interpretation of brain imaging
Rapid laboratory testing
Mix t-PA ahead of time
Rapid access and administration of IV t-PA
Stroke tools:
Stroke order set
Guidelines
Algorithms
Pathways
NIHSS
Inclusion/Exclusion

23. Value Based Purchasing
Beginning in stroke measures will be a part of value based purchasing.

24. It Should All Start with EMS…

25. Role of EMS in Stroke Primary Stroke Centers
Primary Stroke Center recommendations by the Brain Attack Coalition in and updated in 2011 address the vital role the EMS have in the chain of survival for patients with stroke
Primary Stroke Centers must cooperate and communicate with inbound EMS
Primary Stroke Centers are required to meet standards for EMS pre-hospital stroke care
JAMA, Volume 283, Number 23, June
Stroke 2013, Stroke, 2011, and Stroke 2007

26. Notification and Response of Emergency Medical Services (EMS) for Stroke
The notification and response of EMS to a stroke patient is an important part of our process
It involves the public, the EMS systems, and the hospital EDs
Treatment for stroke is most effective if tPA is administered within three hours of symptom onset showing decreased disability
EMS transport of stroke patients to a hospital equipped to treat strokes generally results in better outcomes and reduced disability and death compared to patients who arrive by car or other forms of personal transport

27. Process Improvement for EMS
Goals
Limit stroke disability
Improve relationship with EMS and Emergency Departments
Utilize same language for acute stroke patient throughout region

28. Implementation Stroke Task Force Implemented for District 1 EMS
Committee members
Area EMS providers
Area Stroke Coordinators
Stroke Checklist form developed
Beta Test completed

30. Barriers Found Crews were slow to catch on/unsure of the purpose
Initially, concerns with more paperwork to complete
Where to place the completed forms
ALS vs BLS with compliance/participation

31. Benefits Observed Reminders of important assessment details
Condensed form of information for radio report
Consistent reporting of “stroke” symptoms from the field
Ability to hand hospital staff information immediately

32. Changes Suggested Signatures of crew members
FAST – check boxes – either “Normal” or “Not Normal”

33. Emergency Department Core measure – STK 4, SM 5
Acute ischemic stroke patients who arrive within 120 minutes of time last known well and for whom IV tPA was initiated at this hospital within 180 minutes of time LKW
If patient arrives within 2 hours of onset of symptom onset, should receive thrombolytic treatment within 3 hours (FDA approved)
May go up to 4.5 hours for treatment with consent
If ischemic stroke patient does not receive tPA within this window, documented reason must be in the chart
Utilize tPA inclusion/exclusion criteria

35. ED Improvement Measures
ED Doctors and Nurses receive advanced stroke education, certified in NIHSS assessment
Standardized stroke order sets
One page notification system
Lab and CT took ownership of improvement process for TAT
Future: Possible EMS straight to CT to decrease time to treatment
Door to Needle time less than 60 minutes
New target stroke information, less than 45 minutes
Future: Stroke champion in the ED to review tPA patients
Feedback on misses within one week
Feedback on tPA patients within one week

38. Inpatient Acute Care JC HFAP STK - 1 SM - 1
STK - 1
SM - 1
Venous Thromboembolism (VTE) Prophylaxis
STK - 2
SM - 7
Discharged on Antithrombotic Therapy
STK - 3
SM-8
Anticoagulation Therapy for Atrial Fibrillation/Flutter
STK - 4
SM-5
Thrombolytic Therapy
STK - 5
SM-6
Antithrombotic Therapy By End of Hospital Day 2
STK - 6
SM-10
Discharged on Statin Medication
STK - 8
SM-11
Stroke Education
STK - 10
SM-13
Assessed for Rehabilitation

39. VTE Prophylaxis STK – 1, SM – 1
Patients with an ischemic or hemorrhagic stroke who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or day after hospital admission
Improvement strategies
Organizational policy for VTE
Meaningful use expectations
Quality measures and safety goals
Use of stroke order sets with in the EHR
Training and education
Nursing autonomy/implementation (application of SCDS)
Documentation

40. Discharged on Anti-thrombotic Therapy STK – 2, SM – 7
Patients with an ischemic stroke prescribed anti-thrombotic therapy at discharge
Improvement strategies
Standardized discharge order set specific for stroke
Nursing education including stroke discharge medications

41. Use of e-mail tools to remind staff to monitor measures sent on a daily basis:

42. Improvement Strategies
Patients with Afib/Flutter Receiving Anti-coagulation Therapy STK – 3, SM – 8
Patients with an ischemic stroke with afib/flutter discharged on anticoagulation therapy
Improvement Strategies
Standardized admission and discharge order set
Admission assessment to include history of
afib/flutter or present afib/flutter
EKG monitoring per guidelines
Cardiology consult

43. Anti-thrombotic Therapy by End of Hospital Day 2 STK – 5, SM – 6
Patients with ischemic stroke who receive antithrombotic therapy by the end of hospital day two (day after patient arrival)
Improvement Strategies
Standardized admission order set
Automatic best practice advisory in EMR
Education

44. Discharged on Statin Medication STK – 6, SM – 10
Ischemic stroke patients with LDL > 100 or LDL not measured or who were on cholesterol reducing therapy prior to hospitalization are discharged on Statin medication
Improvement Strategies
Standardized order set and discharge order set
Patient education
Contraindications
Use of hard stop in the EMR if Statin not addressed at discharge

45. Stroke Education STK – 8, SM – 11
Patients with ischemic or hemorrhagic stroke or their caregivers who were given educational materials during the hospital stay addressing all of the following: risk factors for stroke, warning signs for stroke, activation of EMS, the need for follow-up after discharge, and medications prescribed at discharge
Improvement Strategies
Develop a stroke education policy
Who – When – How
Documentation daily in the EMR
Standardize educational materials
Include patient and family in learning expectations

46. Assessed for Rehabilitation STK – 10, SM – 13
Patients with an ischemic or hemorrhagic stroke who were assessed for rehabilitation services
Improvement strategies
Standard order set includes therapy consultations
Protocol for therapy service
Follow up after discharge

49. References:
Centers for Medicare & Medicaid (2014, August 4) CMS to Improve Quality of Care during Hospital Stays Retrieved from
Chang, F. (2006, February 11) Advances in Treatment of Stroke and Intracerebral Hemorrhage Power Point presentation
Cleary, P.D. and O’Kane, M.E. (n. d.) Evaluating the Quality of Health Care National Institutes of Health Retrieved from
Filho J.O., and Koroshetz, W.J. (2014, November 26). Initial assessment and management of acute stroke retrieved from
Shekelle, P. (2014, June 5) Clinical practice guidelines
Stroke Statements and Guidelines American Stroke Association (n.d.) Retrieved from