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CSN INFORMATION AND EVALUATION RESOURCE

CSN INFORMATION AND EVALUATION RESOURCE. Stroke Quality of Care Special Project 340 Data Collection System Developed by the Canadian Stroke Network in collaboration with the Canadian Institute for Health Information (CIHI) and Hamilton Health Sciences Stroke Program.

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CSN INFORMATION AND EVALUATION RESOURCE

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  1. CSN INFORMATION AND EVALUATION RESOURCE Stroke Quality of Care Special Project 340 Data Collection System Developed by the Canadian Stroke Network in collaboration with the Canadian Institute for Health Information (CIHI) and Hamilton Health Sciences Stroke Program

  2. Objectives of Presentation • To set the Context for Stroke Quality of Care Special Project 340 (SQC_SP340) • Purpose of data collection • CSN Core Performance Indicator Set • Link between SQC_SP340 indicators and best practice guidelines • Position SQC_SP340 in context with national stroke audit 2009 • To describe SQC_SP340 Development process • To understand and be able to collect SQC_SP340 Data Elements

  3. CSN Transitions of Care Model STROKE • ~44,000 admitted stroke & TIA patients annually • Even more strokes that are ‘covert’ with a different set of symptoms • 80% caused by blood clots and 20% by bleeding onto the brain • Longest LOS • Leading cause of adult disability • Higher in hospital mortality • Quality of care varies across hospitals, regions and provinces • Very costly to the Healthcare system • Opportunity to improve care exists!

  4. Results- Viewing the Recommendations on the Website

  5. * ^ SPC Referrals *^ Antithrombotic Rx ^ Antithrombotics for A-Fib ^ Time to CEA * ^ Stroke Unit ^ Dysphagia Assessment ^ Rehab assessment within 48 hr ^ Complication Rates Discharge Location ^ Hospital LOS *^ LSN to ED arrival time Stroke Pre Hospital Hyper acute Acute Rehab Prevention Community ^ Admit rates for inpatient rehab ^ Wait times for rehab ^ Change in FIM Score Discharge location Rehab LOS ^ Depression Screening Risk Factors Public Awareness S/S ED/Acute Admissions ^ Mortality ^ Readmission Rates ^ Patient Education *^CT/MRI within 24 hrs * ^ tPA rates * ^ DTN Time ^ ASA within 48 hours Admission rates to LTC & CCC Home care services CSN Core Indicators Update 2010 • System • Clinical • * SQC_SP340 • ^ Accreditation

  6. Stroke audit volumes by province

  7. Goals of Special Project 340 • To build capacity for all hospitals to monitor stroke care delivery consistently regardless of hospital size, location and stroke volumes • To promote standardized and efficient data capture for key process and outcome information based on stroke best practices • To facilitate participation in stroke surveillance, quality improvement, benchmarking and the new Accreditation Canada Stroke Distinction Program • Continue to collect performance data beyond the Quality of Stroke Care Audit

  8. Why Special Project 340? • Efficient and cost-effective • Use of pre-existing data system • Health records staff already review all stroke charts • Additional 5 – 10 minutes per stroke chart • Standardized data collection and central location of data within CIHI • Data accessible to facility and regions routinely • Opportunities for comparative reporting against peers

  9. Not fair!! You cannot include us in the comparisons … we’re special!! But we are different … we are in a rural setting with no resources SQC_SP340 is relevant to all acute care organizations

  10. Development of Project 340 • Discussions between CIHI DAD management and CSN • Data elements selected by CSN IEWG • Review and refinement by CIHI classifications group • Review and approval as a CSN project - Not an ‘official’ CIHI special project therefore not a mandatory project • Bulletin developed and disseminated in June 2009 • Revised bulletin in October 2009 • Included in DAD data manual for 2010 • Starting in NACRS in 2010 for patients d/c from the ED

  11. Determining Feasibility Value of having information Cost to obtain data

  12. Who is participating in SQC_ SP 340?

  13. CIHI Special Project 340_DAD:Stroke Performance Improvement • Date and time of stroke symptom onset (92 – 96) • CT Scan / MRI within 24 hours (80) • Admission to a Stroke Unit (81) • Administration of Acute tPA (82) • Date and Time of Acute tPA (83 – 90) • Rx for Antithrombotic Meds at Discharge (91)

  14. CIHI Special Project 340_NACRS :Stroke Performance Improvement • Date/time of stroke symptom onset (92 – 96) • CT Scan / MRI within 24 hours (80) • Administration of Acute tPA (82) • Date and Time of Acute tPA (83 – 90) • Rx for Antithrombotic Meds at Discharge (91) • Referral to secondary prevention services/clinic (81) NACRS Project 340 Data Elements 79–96

  15. Detailed Data Element Review

  16. Looking at CIHI 340 Elements • Related Best Practice Recommendation • Why it is important to stroke care? • Who are the stroke cases that are included? • What specific data elements are collected? • Whendoes it occur in the episode of care? • Where is this information documented?

  17. Identification of Appropriate Stroke Cases • The data elements included in this project should be completed for all NEW ACUTE ischaemic and haemorrhagic stroke and transient ischaemic attack cases with an ICD-10-CA Most Responsible Diagnosis (MRDx) or Service Transfer (Type [W], [X] or [Y]) recorded FOR NEW STROKE CASES ONLY or Type (1) (pre-admit comorbidity—FOR NEW STROKES ONLY) • Note: When there are multiple strokes of the same type during the same admission, complete the Stroke Project fields for only the initial stroke. CIHI DAD Manual 2011-2012, Page 331

  18. Who should be included in SQC_SP340? Stroke Case Definitions (CSN Jan 2010) MRDx

  19. Inclusions and Exclusions

  20. Stroke Symptom Onset Date and Time

  21. Stroke Symptom Onset Date and Time Canadian Best Practice Recommendations for Stroke Care 3.1 Patients who show signs and symptoms of hyperacute stroke ( onset <4.5 hours) must be treated as time sensitive emergency cases and should be transported without delay to the closest institution that provides emergency stroke care Whyit is important: • Time is brain - Interventions such as tPA are time-sensitive • Delays to assessment and diagnosis increase morbidity and mortality in stroke

  22. Stroke Symptom Onset Date and Time Who • All stroke and TIA patients What • The date and time when the stroke symptoms first started When • On scene by ambulance personnel • Part of the initial evaluation of the patient, in an ED or inpatient setting • history of presenting illness/ chief complaint

  23. Stroke Symptom Onset Date and Time Where you will find it: • Ambulance/EMS record • Triage Nurses’ notes • ED nurses notes • ED physicians note • Admitting MD’s note • Initial Nursing assessment/ intake

  24. Approximating Times of Stroke Onset When Exact Time Not Known( 24 hour clock format)

  25. Stroke Symptom Onset Date and Time CIHI Data Entry (Fields 92 – 96): Year, Month, Day, Hour, Minute • For unknown data record 9 in the missing fields • There should never be a time where 8 (not applicable) is used.

  26. CT Scan/MRI within 24 Hours

  27. CT Scan/MRI within 24 Hours Whyit is important: • Brain imaging is required to guide management • Differentiate between ischemic and hemorrhagic stroke Canadian Best Practice Recommendation for Stroke Care 3.3: All patients with suspected acute stroke or TIA should undergo brain imaging immediately

  28. CT Scan/MRI within 24 Hrs Who • All Ischemic Stroke, Hemorrhagic Stroke and TIA What • Did the patient have some type of initial brain imaging within the first 24 hours after arriving at hospital? When • part of the initial physician evaluation of the patient, usually in an ED or inpatient setting • Within the first 24 hours of arriving to a hospital • ED triage time is considered the arrival to hospital • not registration time or hospital admission time

  29. CT Scan/MRI within 24 Hours Whereyou will find it: • CT report (will have date and time of scan) • ED/ Inpatient nurses notes • Electronic Radiology order/report • ED physician orders • Inpatient physician orders • Diagnostic Procedures log • Transfer notes • Physician Consult notes

  30. CT Scan/MRI within 24 Hours CIHI Data Entry (Field 80): Yes / No • Y if done within 24 hours of arrival • N if not done within 24 hours • P if done at another hospital prior to transfer

  31. Stroke Unit PT OT RN Interprofessional Stroke Unit Bed #4 Admission to a Stroke Unit

  32. Admission to a Stroke Unit Whyit is important: • High level evidence that demonstrates stroke patients who are treated on a stroke unit have lower death and disability rates Canadian Best Practice Recommendation for Stroke Care 4.1: Patients admitted to hospital because of an acute Stroke or TIA should be treated in a designated and geographically defined stroke unit

  33. Special Notes about Stroke Units: Definition of a stroke unit: “ A specialized, geographically defined hospital unit dedicated to the management of stroke patients” (CBPR 4.1) • Do you have a stroke unit? • Each facility should establish if they have a stroke unit that meets the CSN definition • If yes, where is it located in the hospital? • Health records should know where the stroke unit is located (i.e., ward/location code) • Note: clustering of stroke patients in the absence of a stroke unit should not be considered as a ‘yes’ for this measure

  34. Admission to a Stroke Unit Who • All admitted Ischemic Stroke, intracerebral hemorrhagic and TIA patients • Only during acute inpatient care, this does not include admission to a stroke rehab unit, even if in same facility What • Did the patient spend any time during the acute care admission on a designated stroke unit? **Need to confirm whether there is a clearly defined stroke unit When • During admission … • Directly from the ED • After an ICU admission • Transfer from ward when SU bed available

  35. Admission to a Stroke Unit Whereyou will find it: • Hospital Admissions Register • Nurses notes CIHI Data Entry (Field 81): Yes / No • Y if admitted to a stroke unit at any time • N if there is a stroke unit, but the patient was never treated on the stroke unit • 8 if there is no stroke unit at the facility or patient is SAH

  36. 4.5 Administration of Acute Thrombolysis Time is Brain

  37. Administration of Acute Thrombolysis Why it is important: • Strong evidence finds tPA has been shown to reduce risk of disability and death in patients with ischemic stroke treated within 4.5 hours of symptom onset Canadian Best Practice Recommendations for Stroke Care 3.5: All patients with disabling acute ischemic stroke who can be treated within 4.5 hours after symptom onset should be evaluated without delay to determine their eligibility for treatment with IV tPA

  38. Administration of Acute Thrombolysis Who • All Ischemic Stroke patients that present to hospital within 4.5 hours of the onset of stroke symptoms What • Patients who received Alteplase ( tissue plasminogen activase, Activase, tPA, r-tPA) When • Almost always in the ED before patient admitted • Very rarely in other locations such as inpatient or SU

  39. Administration of Acute Thrombolysis Whereyou will find it: • ED r inpatient medication records • MD orders • Most hospitals have preprinted order sets for tPA administration • Progress/ Consult notes • ED nurses notes • Discharge summary

  40. Administration of Acute Thrombolysis CIHI Data Entry (Field 82): Yes / No • Y if the patient received tPA • N if the patient did not receive tPA • P if tPA was given at another facility prior to direct transfer • X if your facility does not provide tPA • 8 Not applicable ( TIA, ICH,SAH)

  41. 4.5 hr Date and Time of Administration of Acute Thrombolysis Time is Brain

  42. Administration Time for Acute Thrombolysis Whyit is important: • tPA is safe only when given within a therapeutic window up to 4.5 hours from symptom onset, so ED’s must mobilize rapidly and efficiently • Inverse relationship between treatment delay and clinical outcomes ( quicker is better) Canadian Best Practice Recommendations for Stroke Care 3.5: All patients with disabling acute ischemic stroke who can be treated within 4.5 hours after symptom onset should be evaluated without delay to determine their eligibility for treatment with IV tPA

  43. Administration Time for Acute Thrombolysis Who • Ischemic Stroke patients that receive tPA What • What is the door-to-needle time for tPA administration? • Did the patient receive Alteplase (tissue plasminogen activase, Activase, tPA, rtPA) as their treatment for acute ischemic stroke within 60 minutes of arrival to ED (Current benchmark target)? When • In ED within the first few hours of arrival • Triage time used as start time for DTNT calculations

  44. Administration Time for Acute Thrombolysis Where you will find it: • tPA is given by an RN in the ED • ED medication record • Medication profile, single order medication • Signature on MD order • Nurses notes • tPA standing order sheet • Should always have the exact time of administration • Time to record is the start time of administration (medication is infused over 1 hour)

  45. Administration Time for Acute Thrombolysis CIHI Data Entry (Fields 83 – 90): • Enter Month, Day, Hour, Minutes • For unknown data record 9 • For not applicable record 88888888 (ICH, SAH, TIA, or if hospital does not give tPA, or the patient DID NOT receive tPA even if they were ischemic)

  46. Prescription for Antithrombotic Medication at Discharge

  47. Prescription for Antithrombotic Medication at Discharge Whyit is important: • Studies on antiplatelets for stroke have found they can reduce further vascular events by more than 25% Canadian Best Practice Recommendations for Stroke Care 2.5: All patients with Ischemic Stroke or TIA should be prescribed antiplatelet therapy for secondary prevention of recurrent stroke unless there is an indication for an anticoagulant

  48. Prescription for Antithrombotic Medication at Discharge Why? • Stroke caused by atrial fibrillation is highly preventable if patients are treated with anticoagulants (blood thinning medications). The risk of another stroke can be reduced by one-third or more in compliant patients. Canadian Best Practice Recommendations for Stroke Care 2.6: For the secondary prevention of stroke, patients with atrial fibrillation who have had a stroke/TIA should be treated with warfarin at a target international normalized ratio of 2.5, range 2.0 to 3.0, if they are likely to be compliant with the required monitoring and are not at high risk for bleeding complications.

  49. Prescription for Antithrombotic Medication at Discharge Who • Ischemic Stroke and TIA patients What • Was the patient prescribed antithrombotic medications for ongoing stroke prevention at discharge? When • At discharge from hospital- either from the ED or inpatient setting

  50. Common Antithrombotic Agents Antiplatelet Agents: • Aspirin (ASA, ECASA) • Clopidogrel(Plavix) • Dipyridamole plus ASA (Aggrenox) • Ticlopidine(Ticlid) Anticoagulants: • Warfarin ( Coumadin) • Dabigitran (Pradax) • Rivaroxaban(Xarelto) • Apixaban(Eliquis) Heparinoids(Injections): • Heparin, Enoxaparin(Lovenox) • Fondaparinux(Atrixa)

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