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

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

3. 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

4. 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

5. 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 ”
“Implementation Expectations” are now called “Elements of Performance”
The Joint Commission Disease-Specific Care Certification, 2009 Chapter: National Patient Safety Goals

6. Goal 1: Improve the accuracy of patient identification
NPSG 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

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

8. Goal 2: Improve effectiveness of communication among caregivers
NPSG 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

9. Goal 2: Improve effectiveness of communication among caregivers
NPSG :
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

10. Goal 2: Improve effectiveness of communication among caregivers
NPSG
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?

11. Goal 2: Improve effectiveness of communication among caregivers
NPSG – 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

12. Goal 2: Improve effectiveness of communication among caregivers
NPSG –
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

13. Goal 2: Improve effectiveness of communication among caregivers
NPSG – 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

14. Goal 2: Improve effectiveness of communication among caregivers
NPSG
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

15. Goal 2: Improve effectiveness of communication among caregivers
NPSG
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?

16. Goal 2: Improve effectiveness of communication among caregivers
NPSG – 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

17. Goal 2: Improve effectiveness of communication among caregivers
NPSG –
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

18. Goal 2: Improve effectiveness of communication among caregivers
NPSG –
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

19. Goal 2: Improve effectiveness of communication among caregivers
NPSG
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

20. Goal 2: Improve effectiveness of communication among caregivers
NPSG
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

21. Goal 7: Reduce the risk of health care associated infections
NPSG 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.

22. Elements of Performance:
Goal 8: Accurately and completely reconcile medications across the continuum of care
NPSG – 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

23. Elements of Performance Con’t:
Goal 8: Accurately and completely reconcile medications across the continuum of care
NPSG –
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

24. 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?

25. 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

26. Goal 8: Accurately and completely reconcile medications across the continuum of care
NPSG – 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

27. Elements of Performance:
Goal 8: Accurately and completely reconcile medications across the continuum of care
NPSG
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

28. Goal 8: Accurately and completely reconcile medications across the continuum of care
NPSG
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

29. 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?

30. Elements of Performance:
Goal 8: Accurately and completely reconcile medications across the continuum of care
NPSG (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

31. Goal 8: Accurately and completely reconcile medications across the continuum of care
NPSG (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

32. Goal 8: Accurately and completely reconcile medications across the continuum of care
NPSG
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

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

34. Goal 9: Reduce the risk of patient harm resulting from falls
NPSG – 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

35. Goal 9: Reduce the risk of patient harm resulting from falls
NPSG –
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

36. Goal 9: Reduce the risk of patient harm resulting from falls
NPSG –
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

37. Elements of Performance:
Goal 10: Reduce the risk of influenza and pneumococcal disease in institutionalized older adults
NPSG 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

38. Elements of Performance:
Goal 10: Reduce the risk of influenza and pneumococcal disease in institutionalized older adults
NPSG 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

39. Elements of Performance:
Goal 10: Reduce the risk of influenza and pneumococcal disease in institutionalized older adults
NPSG 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

40. Goal 13: Encourage patient’s active involvement in their own care as a patient safety strategy.
NPSG 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

41. Elements of Performance:
Goal 13: Encourage patient’s active involvement in their own care as a patient safety strategy.
NPSG
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

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

43. Universal Protocol
UP 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

44. 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

45. 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

46. Universal Protocol
UP 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

47. 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

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