Staff of 2NE, 2W and Telemetry Admitting Center for Clinical Effectiveness

1. Core Team:Leslie Barna, RN, MSN Jose Biller, MDBarbara Buturusis, RN, MSNLinda Chadwick, RN, BSNRima Dafer, MD Ann HahnMary Healey, RN, BS Lisa Millsap, PharmD, ACNPMichael Schneck, MD Staff of 2NE, 2W and Telemetry Admitting Center for Clinical Effectiveness Center for Home Care & Hospice Clinical Neurodiagnostic Laboratory Education and Support Services Emergency Department Human Resources/Organizational Development Interventional Radiology Laboratory Marketing Medical Records Neurosurgery Nutrition Pastoral Care Primary Care Psychiatry Rehabilitation Services Social Work

2. PLAN • Project Aim Statement • To standardize and improve care for acute stroke and transient ischemic attack (TIA) patients from the time the patient has stroke symptoms through the rehabilitation phase. • To achieve JCAHO Disease Specific certification for the Stroke program by demonstrating compliance with standards and Brain Attack Coalition guidelines for stroke care.

3. “Get with the Guidelines” On - Line Patient Management Tool • Using Plan, Do, Study, Act we pursue 100% compliance with: • JCAHO 1 DVT Prophylaxis • JCAHO 2 Discharge on Anti-Thrombotics • JCAHO 3 A. Fib. Patients Discharged on Anticoagulants • JCAHO 4A rt - PA Considered and Documented • JCAHO 4B rt - PA Administered – when appropriate • JCAHO Disease Specific Standards • Stroke Program Guidelines How the Stroke Program Monitors and Improves Quality

4. DO – Solutions Implemented • Implemented evidence based clinical guidelines and standard orders for stroke care • Initiated a Stroke Immediate Response Team (pager 14911) • Initiated Stroke patient database and analyzed results • Standardized Neurology H & P and progress note • Daily multidisciplinary rounds • 10 Acute or Preventive Stroke Clinical Trials

5. DO – Design & Implement Team Structure • Acute Team • Begins with Hospital admission; Ends with Hospital discharge • Opened Acute Stroke Unit • Global nursing education • Standardized order sets • Stroke Guidelines • Pre ED and ED Team • Begins in the Community; Ends with ED discharge • Stroke Education Program (e-learning) • Rapid Response - Lab Analysis • Rapid Response - Radiology CT • Code Red -Elevated Triage Level • Implemented Clinical Trials • Stroke Prevention Team • Coordination of professional and community education • Stroke Month Activities: Staff & management education, • Stroke Screening and Risk Factor Assessment • Smoking Cessation Classes • Stroke Support Group • Power to End Stroke in African American Community (May 06) • Community Television Ad (Spring 06) • Web Site Development • Patient Education Standardization • Rehab Team • Begins with Hospital admission; Ends with Rehab discharge • Daily Multidisciplinary Rounds • Rehab Level of Care criteria • Weekend therapy sessions • Neuro Therapy Team - consistency of therapists

6. January 2005 - December 2005 160 140 120 UCL = 117.82 100 Percent Mean = 94.95 80 LCL = 72.08 60 40 01/05 06/05 03/05 12/05 02/05 04/05 05/05 07/05 08/05 09/05 10/05 11/05 Month STUDY • Patients with ischemic stroke (non-ambulatory) received DVT prophylaxis by Day 2 Since May 2005, the team achieved 100%

7. January 2005 - December 2005 January 2005 - December 2005 100.010 100.010 100.005 100.005 Percent Percent 100.000 100.000 99.995 99.995 99.990 99.990 01/05 02/05 03/05 04/05 05/05 06/05 07/05 09/05 09/05 10/05 11/05 11/05 12/05 01/05 02/05 03/05 04/05 05/05 07/05 06/05 08/05 10/05 Month Month STUDY 100% of patients with acute ischemic stroke or TIA and atrial fib. were discharged on anticoagulants • 100% of patients with acute ischemic stroke or TIA received antithrombotic therapy within 48 hours of admission

8. January 2005 - December 2005 January 2005 - December 2005 t 200 180 150 UCL = 139.19 160 UCL = 159.16 Percent 100 140 Mean = 68.57 120 50 Percent 100 Mean = 88.89 LCL = 0.00 0 01/05 05/05 07/05 10/05 11/05 12/05 04/05 06/05 09/05 80 Month 60 40 20 LCL = 18.62 05/05 06/05 07/05 11/05 12/05 Month STUDY • Patients with ischemic stroke who present to the hospital within 3 hours of symptom onset are: a. Considered for rt-PA b. Receive rt-PA if indicated Team working to improve Team working on meeting criteria documentation in all clinical settings

9. ACT – Next Steps • Monitor compliance with JCAHO standards and quality indicators and continue to improve documentation • Customize Stroke patient education tool • NIH Stroke Scale Certification • Ongoing staff education • Continue and expand community outreach targeting high risk populations • Promote consistent utilization of stroke guidelines and order sets for off service patients • Increase the number of participants in clinical trials • Submit JCAHO intra-cycle report including measures of success (January 2007)

10. ACCOMPLISHMENTS Achieved the first JCAHO Disease Specific Certification at LUHS • Standardized stroke care and improved quality • Initiated program of clinical trials • Established engaged, interdisciplinary cross-continuum teams • Secured capital funding and initiated Acute Stroke Unit • Received LUHS Leadership Award