Quality of Care for Stroke Patients

1. Quality of Care for Stroke Patients Jerilyn Alexander, RN Stroke Coordinator Trinity Health

2. Quality • Everyone wants it whether it is for your house, your car, or healthcare! • Quality healthcare is a measurement of the healthcare received at your Dr.’s office, the ER, or during a hospital stay • It goes beyond the manners and attitude of health care providers

3. Definition • According to the Institute of Medicine it is defined as “the extent to which health services provided to individuals and patient populations improve desired health 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.”

4. Quality Improvement • A formal approach to the analysis of performance and systematic efforts to improve it. • Key word is Improvement • Always strive for the best outcome!

5. Stroke Care • How do we get a sense of the quality? • What’s the best way to care for stroke patients? • Are there guidelines for care of a stroke patients?

6. Stroke Care • Guidelines: • 2007 AHA/ASA Guidelines for the Early Management of Adults with Ischemic Stroke • 2011 Revised and Updated Recommendations for the Establishment of Primary Stroke Centers • 2009 Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Stroke patient: A Scientific Statement from the American Heart Association

7. 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. • Began the Certification Program in 2003.

8. Primary Stroke Center Certification • BAC Recommendations • Establishing Criteria for emergency response • Availability of neuroimaging 24/7 • Laboratory, Neurology, and Neurosurgery support • Administrative Support • Appropriate Staff Education • Outcomes tracking.

9. State of North Dakota • Developing Statewide Stroke System of Care • Similar to State Trauma System • Encouraging all Tertiary Centers to become Primary Stroke Centers • Sanford-Fargo and St. Alexius Bismarck are currently only 2 certified but all centers are pursuing it.

10. Certification Requirements • Use standardized method of delivering care based on BAC recommendations for establishment of primary stroke centers • Support a patient’s self management activities • Tailor treatment and intervention to individual needs • Promote the flow of patient information across settings and provides while protecting patient rights, security and privacy • Analyze and use standardized performance measure data to continually improve treatment plans • Demonstrate their application of and compliance with the clinical guidelines published by AHA/ASA or equivalent evidence-based guidelines.

11. 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 • Stroke Education (Ischemic and Hemorrhagic) • Assessed for Rehab (Ischemic and Hemorrhagic)

12. 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?

13. 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. • Outcome Sciences database can benchmark to other facilities.

14. Stroke Quality • 8 indicators for ischemic stroke patients and 3 of these same indicators are looked at for hemorrhagic stroke patients. • GWTG looks at 9 indicators primarily looking at timeliness in the emergency phase of presentation. • CMS looks at 3 different areas (Stroke, VTE, ED), with some overlap of the Joint Commission Indicators. For stroke they will look at 7 indicators.

15. 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

16. 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)

17. STK-1 Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission. Time Period: Q1 2011 - Q4 2011; Site: Trinity Hospitals (52674) Data For: STK-1 Data For: STK-1 Benchmark Group Time Period Numerator Denominator % of Patients All ND Hospitals Q1 2011 109/125 87.2% All ND Hospitals Q2 2011 131/149 87.9% All ND Hospitals Q3 2011 128/156 82.1% All ND Hospitals Q4 2011 143/171 83.6%

18. 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

19. Discharged on Antithrombotic Therapy • Antiplatelet orAnticoagulant 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

20. STK-2 Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. Time Period: Q1 2011 - Q4 2011 Data For: STK-2 Benchmark Group Time Period Numerator Denominator % of Patients All ND Hospitals Q1 2011 109/110 99.1% All ND Hospitals Q2 2011 131/133 98.5% All ND Hospitals Q3 2011 153/155 98.7% All ND Hospitals Q4 2011 154/155 99.4%

21. 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

22. STK-3 Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge. Time Period: Q1 2011 - Q4 2011 Data For: STK-3 Benchmark Group Time Period Numerator Denominator % of Patients All ND Hospitals Q1 2011 12/12 100.0% All ND Hospitals Q2 2011 21/23 91.3% All ND Hospitals Q3 2011 21/26 80.8% All ND Hospitals Q4 2011 32/35 91.4%

23. 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

24. STK-4 Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well. Time Period: Q1 2011 - Q4 2011 Data For: STK-4 Benchmark Group Time Period Numerator Denominator % of Patients All ND Hospitals Q1 2011 6/13 46.2% All ND Hospitals Q2 2011 7/11 63.6% All ND Hospitals Q3 2011 3/11 27.3% All ND Hospitals Q4 2011 1/10 10.0%

25. 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

26. STK-5 Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2. Time Period: Q1 2011 - Q4 2011 Data For: STK-5 Benchmark Group Time Period Numerator Denominator % of Patients All ND Hospitals Q1 2011 94/99 94.9% All ND Hospitals Q2 2011 108/116 93.1% All ND Hospitals Q3 2011 135/141 95.7% All ND Hospitals Q4 2011 135/ 40 96.4%

27. 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

28. STK-6 Ischemic stroke patients with LDL >= 100 mg/dL, or LDL not measured, or, who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge. Time Period: Q1 2011 - Q4 2011 Data For: STK-6 Benchmark Group Time Period Numerator Denominator % of Patients All ND Hospitals Q1 2011 69/84 82.1% All ND Hospitals Q2 2011 93/102 91.2% All ND Hospitals Q3 2011 98/117 83.8% All ND Hospitals Q4 2011 99/117 84.6%

29. 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 Stroke Coordinator consult at Trinity, that alerts the need for education to patients with strokes or TIA’s.

30. STK-8 Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke. Time Period: Q1 2011 - Q4 2011 Data For: STK-8 Benchmark Group Time Period Numerator Denominator % of Patients All ND Hospitals Q1 2011 35/48 72.9% All ND Hospitals Q2 2011 45/70 64.3% All ND Hospitals Q3 2011 56/85 65.9% All ND Hospitals Q4 2011 59/83 71.1%

31. Assessed for Rehab • Assessment must be completed by any one member of the Rehab team including: • Physiatrist • Neuro-psychologist • Physical Therapist • Occupational Therapist • Speech Therapist

32. STK-10 Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services. Time Period: Q1 2011 - Q4 2011 Data For: STK-10 Benchmark Group Time Period Numerator Denominator % of Patients All ND Hospitals Q1 2011 120/123 97.6% All ND Hospitals Q2 2011 143/148 96.6% All ND Hospitals Q3 2011 154/163 94.5% All ND Hospitals Q4 2011 166/173 96.0%

33. 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.

34. STK-1 VTE Prophylaxis

35. Analysis • Review each case, found that SCD’s were being ordered since it was a pre-checked order on standard stroke order set. This was done so that if Lovenox was not ordered they would at least meet indicator with SCD’s • Nursing was not placing SCD’s on the patient or not documenting it in the HER.

36. STK 1-Compliance Action Plan • December 2011-Worked with Informatics to develop report that prints at each nurses station every shift, reporting which patients have orders for SCD’s or Foot pumps • December 2011- Included quality indicators in in-services on Ischemic stroke to make nursing staff more aware • January 2012-Worked with Clinical Nurse Educators on compliance with staff • January 2012-Will have the SCD or Foot pump order fire a task for nursing to complete upon application of SCD’s or foot pumps. Going to Profession Practice Committee in February 2012.

37. Follow up • This continues to be a work in progress • Follow up with staff, physicians with the corrective plan of action. • Frequent updates to Clinical Educators if compliance drops off.

38. GWTG Stroke Measures • Door to MD evaluation-10 Minutes • Door to CT Scan-25 minutes • Door to CT Scan Interpretation-45 minutes • Door to EKG-45 minutes • Door to Lab Results-45 minutes • Door to IV tPA-60 minutes • Door to CXR-45 minutes • Door to admission-3 hours

39. Stroke Treatment

40. Action Plan • Instituted Stroke Alert for patients that present with symptom onset less than 8 hours. • Mobilizes a team to respond and alerts the Neurologist of potential stroke patient • Once that was in place for several months began to break down the process and look at the data

41. %Door To CT <= 25min Percent of patients who receive brain imaging within 25 minutes of arrival Time Period: Q1 2011 - Q4 2011 Data For: %Door To CT <= 25min Benchmark Group Time Period Numerator Denominator % of Patients My Hospital Q1 2011 10.0% My Hospital Q2 2011 22.5% My Hospital Q3 2011 9.7% My Hospital Q4 2011 17.1% All Hospitals Q1 2011 24.7% All Hospitals Q2 2011 24.8% All Hospitals Q3 2011 24.8% All Hospitals Q4 2011 24.9%

42. Quality issues • Break down the process, why is it taking so long? • Nursing delay (IV placement, assessment)? • Lab delay (Delay due to drawing blood taking too long)? • EKG delay • Radiology (Delay in transport, logistics of transport, delay in staff coming to the ETC)? • What % of our patients are getting CT in 25 minutes?

43. Action Plan • New PI Process form for timing of stroke alerts • Educate staff on new form • Review process of assessment with Nursing staff in the ETC • Continue to work with Radiology regarding timeliness of CT scan results. • Continue to follow up with involved departments

44. Meaningful Use Meaningful Use is using certified EHR technology to • Improve quality, safety, efficiency, and reduce health disparities • Engage patients and families in their health care • Improve care coordination • Improve public health • All the while maintaining privacy and security Meaningful Use mandated in law to receive incentives

45. What are the Three Main Components of Meaningful Use? The Recovery Act specifies the following 3 components of Meaningful Use: • Use of certified EHR in a meaningful manner (e.g., e-prescribing) • Use of certified EHR technology for electronic exchange of health information to improve quality of health care • Use of certified EHR technology to submit clinical quality measures(CQM) and other such measures selected by the Secretary

46. “Core measures” • Core measure program is completely separate from the Meaningful Use Quality Reporting Program • Core measure data elements are captured manually from patients final bill • E-measures are captured electronically • Core measure definitions come from a list that the abstractor chooses from (ICD-9 codes) • Meaningful use measures come from SNOMED

47. How to comply • Will software be able to pull this data and be Meaningful Use compatible? • Will elements need to be built into the system to retrieve this data?

49. MU: Clinical Quality Measures Eligible Hospitals and CAHs must complete all 15: • Emergency Department Throughput –admitted patients Median time from ED arrival to ED departure for admitted patients 2. Emergency Department Throughput –admitted patients –Admission decision time to ED departure time for admitted patients 3. Ischemic stroke –Discharge on anti-thrombotics 4. Ischemic stroke –Anticoagulation for A-fib/flutter 5. Ischemic stroke –Thrombolytic therapy for patients arriving within 2 hours of symptom onset 6. Ischemic or hemorrhagic stroke –Antithrombotic therapy by day 2 7. Ischemic stroke –Discharge on statins 8. Ischemic or hemorrhagic stroke –Stroke education 9. Ischemic or hemorrhagic stroke –Rehabilitation assessment 10. VTE prophylaxis within 24 hours of arrival 11. Intensive Care Unit VTE prophylaxis 12. Anticoagulation overlap therapy 13. Platelet monitoring on unfractionated heparin 14. VTE discharge instructions 15. Incidence of potentially preventable VTE

50. CMS Stroke Indicators • Discharged on Antithrombotic • Anticoagulation Therapy for At Fib/Flutter • Thrombolytic Therapy within 3 hours if patient arrives within 2 hours • Antithrombotic Therapy by end of Hospital Day 2 • Discharged on Statin Medication • Stroke Education (Ischemic and Hemorrhagic) • Assessed for Rehab (Ischemic and Hemorrhagic)