Download File - Jill Collins MSN Portfolio

Quality Improvement In
Stroke Care For Primary
Stroke Center Certification
at St. Francis Health
Center
Washburn University
Master’s Project by:
Jill Collins, RN BSN
December 2012
What Is Primary Stroke Center
Certification?
 It is a program developed in 2003 by The Joint
Commission in collaboration with The American
Heart Association/American Stroke Association
 Initiated in an effort to raise the bar for hospital
stroke care
 Recognizes centers who follow best practices for
stroke care
2
Why Become Primary Stroke Center
Certified?
 To provide our patients with the highest quality
stroke care in order to eliminate or reduce disability
and return them as near as possible to their previous
functional capacity.
 To ensure the highest level of reimbursement for the
quality care that we give
3
Why Address Stroke Care?
Stroke Statistics
• 3rd leading cause of death in the U.S. annually
• Approximately 795,000 people are diagnosed with a
stroke yearly
• 140,000 stroke related deaths occur annually
• Many health conditions which are risk factors for stroke
are on the rise in the U.S. including obesity, diabetes
and hypertension
• In 2010, approximately $73.7 billion was spent on
stroke-related medical costs and disability
4
What Are the Elements of Primary
Stroke Center Certification?
 Use of a standardized method of delivering care
 Support patient self-management activities
 Tailor treatment and interventions to individual needs
 Promote flow of patient information across settings
and providers while maintaining HIPPA
 Analyze and use standardized performance
measure data to continually improve treatment
plans
 Demonstrate application of and compliance with
clinical practice guidelines as established by
American Heart Association/American Stroke
Association
5
Quality and Performance Improvement
 Very important aspect of providing the best quality of
care
 Requirement for Primary Stroke Center Certification
 Involves continual data extraction from charts, input
into database, analysis of data, recognition of areas
needing improvement, implementing a plan of action
and re-evaluation.
6
“Get With the Guidelines-Stroke”
Registry (GWTG-Stroke)
 National database registry for entry of performance data
on specified outcomes which include items such as those
found in the stroke core measure set and recommended
best care practices from the American Heart
Association/American Stroke Association
 Also provides information such as demographics,
admitting diagnoses, discharge diagnoses, treating
providers and pre-existing risk factors of patients
 Allows hospitals to not only monitor their own
performance internally but also allows for comparison
with hospitals of similar size and comparison to hospitals
within the state, region and nation
 Was recently initiated at St. Francis Health Center and
currently has data on over 200 patients as part of my
master’s project
7
St. Francis Health Center Performance
Data from GWTG-Stroke
 The following slides will review data collected from
the
registry in regard to performance at St. Francis. This
shows some of the demographics and well as select
areas of performance. Each performance area will have
prior explanation as to why it was chosen to be included
in this presentation.
 For purposes of data graphs: “Baseline data” is obtained
from 30 random stroke charts from 1/1/11 to 6/30/11,
“2011 data” is from all stroke charts from 7/1/11 to
12/31/11, “current data” is from all stroke charts from
1/1/12 to 8/31/12 and “all hospitals” is data taken from
participating hospitals across the nation from 1/1/12 to
8/31/12.
8
What Does Our Stroke Patient
Population Look Like?
Gender
70%
60%
62%
50%
40%
38%
30%
20%
10%
0%
Female
Male
9
What Does Our Stroke Patient
Population Look Like?
Age in years
60%
56%
50%
40%
30%
26%
20%
16%
10%
0%
2%
18-45
46-65
66-85
>85
10
What Does Our Stroke Patient
Population Look Like?
Race
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
87%
White
10%
2%
1%
African American
Hispanic
American Indian
11
What Kind Of Medical Problems Do
Our Stroke Patients Have?
Pre-existing Diagnoses
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
80%
52%
39%
32%
21%
20%
17%
12
What Types of Strokes Do Our Patients
Have?
Stroke Type
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
87%
13%
Ischemic
Hemorrhagic
13
What are Core Measure Sets?
 A core set of recommended best practices to follow
in regard to a given diagnosis
 A method for The Joint Commission and Medicare to
identify and prioritize unresolved issues regarding
healthcare performance
 Play an important role in establishing and
maintaining Joint accreditation and receiving
Medicare reimbursement
 Current core measure sets are established for stroke,
MI, pneumonia, CHF and surgical infection
prophylaxis
 Goal to be above 90% in all areas
14
Core Measure Performance at St.
Francis From GWTG-Stroke Database
1. Venous thromboembolism prophylaxis (VTE). Documentation
should be made of either having an ambulatory status or receiving
VTE prophylaxis by the end of hospital day 2. This can be
accomplished by administering subcutaneous unfractionated heparin,
low-molecular weight heparins or heparinoids in patients with acute
ischemic strokes. If there are contraindications to anticoagulants or
the patient has had a hemorrhagic stroke, intermittent pneumatic
compression devices or elastic stockings are recommended.
Rationale: patients who experience a stroke in which a lower
extremity is paralyzed or paretic or who are otherwise nonambulatory have increased risk of developing VTE or pulmonary
embolism (PE). PEs account for 10% of deaths after stroke. VTE
prophylaxis has been shown to lower the risk of VTE and PE by 7080% in clinical trials (Outcome Sciences Inc., 2011).
15
St. Francis Data on VTE Prophylaxis
VTE Prophylaxis By End of Hospital Day 2
120%
100%
80%
100%
92%
83%
82%
60%
40%
20%
0%
Baseline
2011
Current
All Hospitals
16
Core Measure Performance at St.
Francis From GWTG-Stroke Database
2. Antithrombotics prescribed at discharge if the patient was
diagnosed with non-cardioembolic ischemic stroke or transient
ischemic attack. Antiplatelets rather than oral anticoagulation are
recommended to reduce the risk of recurrent stroke and other
cardiovascular events. Aspirin (50-325mg/day), Aggrenox (25/200
mg BID) or clopidogrel (75 mg/day) are all recommended therapies.
Rationale: substantial evidence has been accumulated from many
large clinical trials which support the effectiveness of antithrombotic
agents in reducing stroke mortality, stroke-related morbidity and
recurrence rates. If the stroke is due to a cardioembolic source (i.e.
atrial fibrillation or mechanical heart valve), warfarin is the preferred
choice unless contraindicated (Outcome Sciences Inc., 2011).
17
St. Francis Data on Antithrombotics at
Discharge
Antithrombotics Prescribed at Discharge
101%
100%
100%
100%
99%
99%
98.5%
98.6%
98%
98%
98%
97%
Baseline
2011
Current
All Hospitals
18
Core Measure Performance at St.
Francis From GWTG-Stroke Database
3. Anticoagulation prescribed for atrial fib/atrial flutter. Patients
with an ischemic stroke or transient ischemic attack who also have
atrial fibrillation and/or atrial flutter should be discharged home on
anticoagulation. Warfarin is the preferred treatment with dosages
given to achieve an international normalized ratio (INR) of 2.0 to 3.0.
If patients are unable to take anticoagulants, aspirin alone is
recommended. Rationale: non-valvular atrial fibrillation is a common
arrhythmia and has been identified as a substantial risk factor for
stroke. In several clinical trials done on patients with atrial fibrillation,
the use of warfarin has been shown to decrease the relative risk of
thromboembolic stroke by 68%.
19
St. Francis Data on Anticoagulants for
Atrial Fib/Flutter
Anticoags Prescribed for Atrial Fib/Flutter
120%
100%
100%
80%
93%
82%
67%
60%
40%
20%
0%
Baseline
2011
Current
All Hospitals
20
Core Measure Performance at St.
Francis From GWTG-Stroke Database
4. IV tPA arrive by 2 hour, treat by 3 hour. Patients with acute
ischemic stroke who arrive within 2 hours of the time they were last
known to be well should have IV tPA initiated within 3 hours of the
time last known to be well. These patients must meet inclusion
criteria as established by the American Heart Association. Rationale:
several clinical trials show favorable outcomes (defined as complete
or nearly complete neurological recovery 3 months after a stroke)
were achieved in 31-50% of patients treated with IV tPA within 3
hours of onset of symptoms . The major society practice guidelines
developed in the US all recommend the use of IV tPA for eligible
patients (Outcome Sciences Inc., 2011).
21
St. Francis Data on IV tPA Arrive By 2
Hours, Treat by 3 Hours
IV tPA Arrive By 2 Hour, Treat By 3 Hour
90%
80%
70%
79%
Current
All Hospitals
70%
60%
50%
78%
57%
40%
30%
20%
10%
0%
Baseline
2011
22
Core Measure Performance at St.
Francis From GWTG-Stroke Database
5. Early antithrombotics. Patients with ischemic stroke or transient
ischemic attack should receive antithrombotic therapy by the end of
hospital day 2. The recommended agents are the same as listed
above in the “antithrombotics at discharge” section for the same
rationale. Data suggests that antithrombotic therapy should be
initiated within 48 hours of symptoms onset in order to reduce
morbidity and mortality (Core Measure Sets: Stroke, 2011).
23
St. Francis Data on Early
Antithrombotics
Antithrombotic Therapy By End of Hospital Day 2
101%
100%
100%
99%
99%
98%
98%
97%
97%
96%
96%
100%
98%
97%
Baseline
2011
97%
Current
All Hospitals
24
Core Measure Performance at St.
Francis From GWTG-Stroke Database
6. LDL 100 or not documented discharged on statin. Patients with
ischemic stroke or transient ischemic attack with an LDL greater than or
equal to 100, not measured or already on a cholesterol reducing agent prior
to admission should be discharged on a statin medication unless there is a
documented contraindication such as allergy. Rationale: Elevated serum
lipid levels are a well-documented risk for coronary artery disease and
reflects an organ-specific manifestation of atherosclerosis which is a disease
process that can affect the heart as well as major and minor branches of the
arterial tree. Symptomatic carotid artery disease is one of the recognized
coronary disease risk equivalents. The Stoke Prevention by Aggressive
Reduction in Cholesterol Levels (SPARCL) study examined the effects of
statins to lower LDL cholesterol in patients with stroke or transient ischemic
attack of atherosclerotic origin who had no other reason for taking lipid
lowering therapy and had a fasting LDL of greater than or equal to 100
mg/dL. This trial convincingly demonstrated that intensive lipid lowering
therapy using statin medication was associated with a dramatic reduction in
the rate of recurrent ischemic stroke and major coronary events (Core
Measure Sets: Stroke, 2011).
25
St. Francis Data on LDL Results and
Statin Prescription
LDL 100 or Not Documented Discharged on Statin
94%
92%
90%
88%
86%
84%
82%
80%
78%
76%
74%
93%
92%
89%
81%
Baseline
2011
Current
All Hospitals92
26
Core Measure Performance at St.
Francis From GWTG-Stroke Database
7. Stroke Education. Patients with stroke or transient ischemic
attack or their caregivers should be given on education and/or
educational materials during the hospital stay addressing all of the
following: personal risk factors, warning signs for stroke, activation of
emergency medical system, need for follow-up after discharge and
medications prescribed. There should be a specific team member
identified to provide information to the patient and caregiver.
Rationale: many examples of how patient education programs for
specific chronic conditions have increased healthy behaviors,
improved health status and/or decreased health costs of their
participants. Some clinical trials show measurable benefits in patient
and caregiver outcomes with the application of education and support
strategies (Outcome Sciences Inc., 2011).
27
St. Francis Data on Stroke Education
Stroke Education
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
86%
89%
Current
All Hospitals
64.5%
57%
Baseline
2011
28
Core Measure Performance at St.
Francis From GWTG-Stroke Database
8. Rehabilitation considered. All patients diagnosed with stroke
should be assessed for rehabilitation services. When the patient is
medically stable, a consult should be placed for rehabilitation
services to assess patient impairments as well as activity and
participation deficiencies to establish the patient’s rehabilitation
needs and goals. It is strongly recommended that patients with mild
to moderate disability in need of rehab services have access to a
setting with coordinated and organized rehabilitation care team which
is experienced in providing stroke services. Rationale: of the
795,000 patients who experience a new or recurrent stroke annually,
about 2/3 survive and require rehab. A large body of evidence
indicates better clinical outcomes when these patients are treated in
a setting which provides coordinated, multidisciplinary stroke-related
evaluation and services. These treatments can enhance the recovery
process and minimize functional disability (Outcome Sciences Inc.,
2011).
29
St. Francis Data on Rehab Assessment
Rehabilitation Assessment
101%
100%
100%
99%
99%
98%
98%
97%
97%
96%
96%
100%
100%
100%
97%
Baseline
2011
Current
All Hospitals
30
The “Golden Hour” of Stroke Care
The benefit of IV thrombolytic therapy in acute brain ischemia is very much
time dependent. Therapeutic yield is maximal in the first minutes after the
onset of symptoms and decreases during the next 4.5 hours. In a typical
ischemic stroke, for each minute reperfusion is delayed, 2 million nerve cells
die. In every 100 patients treated with IV thrombolytic therapy, for every 10
minute delay in the start of lytic infusion within the 1 to 3 hour treatment
window, 1 fewer patient has an improved disability outcome. Because of the
critical importance in rapid treatment, national recommendations for hospitals
that accept acute stroke patients in their Emergency Departments are to
complete the clinical and imaging evaluation of the patient and initiate lytic
therapy within 1 hour (the golden hour) of patient arrival. The Joint
Commission target for primary stroke centers is to achieve a door-to-needle
time (arrival to start of IV lytic therapy) of within 60 minutes in 80% or more
of patients (Saver, et al., 2010). In order for patients to have IV lytics
started, a certain sequence of events has to occur including evaluation by
the MD, initiation of labwork, NIH stroke scale completed, CT scan of the
brain done within 25 minutes and interpreted by a radiologist and review of
eligibility for tPA. This also would mean that the goal for NIH stroke scale and
door to CT < 25 minutes be 80% or more.
31
St. Francis “Golden Hour” of Stroke
Care Data
Door to CT < 25 Minutes
60%
50%
52%
40%
39.5%
30%
27%
26%
20%
10%
0%
Baseline
2011
Current
All Hospitals
32
St. Francis “Golden Hour” of Stroke
Care Data
NIHSS Reported
90%
80%
78.5%
70%
60%
73%
64%
50%
53.00%
40%
30%
20%
10%
0%
Baseline
2011
Current
All Hospitals
33
St. Francis “Golden Hour” of Stroke
Care Data
Door To Needle Time Within 60 Minutes
60%
50%
50%
40%
39%
37.5%
30%
20%
10%
0%
0%
Baseline
2011
Current
All Hospitals
34
Dysphagia Screening
Dysphagia screen: one of the common
presentations for stroke patients is difficulty talking
and swallowing. The origin of these manifestations
also put the patient at risk for aspiration. Because of
this, a bedside dysphagia screen should be
performed by a nurse and if the patient does not
pass this, a formal swallow study should be done by
speech therapy before the patient has anything by
mouth including medication
35
St. Francis Data for Dysphagia
Screening
Dysphagia Screen Complete
90%
80%
70%
78%
79%
82%
Current
All Hospitals
60%
50%
54%
40%
30%
20%
10%
0%
Baseline
2011
36
Smoking Cessation Education
Smoking cessation education. Smoking is a
common and modifiable risk factor for stroke.
Education and assistance are key to eliminating this
risk factor.
37
St. Francis Data on Smoking Cessation
Education
Smoking Cessation Education
101%
100%
100%
99%
99%
98%
98%
97%
97%
96%
96%
100%
100%
100%
97%
Baseline
2011
Current
All hospitals
38
What Areas Do We Need to Work On?
The following are core measure items that fall below
the 90% goal for purposes of the GWTG-Stroke data:
 VTE Prophylaxis
 Discharge on anticoags if patient has afib/flutter
 Stroke Education
 IV tPA in 3 hours if arrived by hour 2
39
What Areas Do We Need to Work On?
The following items currently fall below the suggested
80% benchmark as per The Joint Commission in
regard to the “Golden Hour” of stroke care:
 NIHSS initially completed
 Door to Needle less than 60 minutes
 Door to CT < 25 minutes
Final item for improvement:
 Dysphagia Screening
40
Recommendations
 Return Stroke Coordinator position to an associate who solely works
on improving stroke care and possibly other quality improvement
projects. This person can then be responsible for the following which
would likely improve scores and quality of care:
– Consistent and continual education throughout the facility on
stroke care requirements and recommendations
– Monitoring core measures as well as GWTG recommendations
– Following up with patient care teams to review care given and
make suggestions for improvement. This would help with
accountability
– Maintain the GWTG-Stroke database for St. Francis, analyze
findings and implement changes
– Work closely with the medical director of the stroke program to
ensure policies, procedures and order sets are consistent with
best-practice guidelines
41
Summary
In all, St. Francis Health Center really is doing a great
job in providing quality stroke care. There are just a
few items needing improvement. Most of these items
are showing steady improvement. The items that
have the lowest performance are still quite
comparable and in some cases even better than
hospitals nationwide. With additional and continual
education and monitoring, I think these numbers
would soon all be at goal.
42
References
Core Measure Sets: Stroke. (2011, February 4). Retrieved April 25, 2012, from The Joint Commission:
http://www.jointcommission.org/core_measure_sets.aspx
George, M. G., Tong, X., & Yoon, P. W. (2011, February 25). Morbidity and Mortality Weekly Report (MMWR).
Retrieved January 15, 2012, from Centers for Disease Control:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6007a2.htm
Katz, M. J. (2010). Stroke: A Comprehensive In-Depth Review. Retrieved July 3, 2012, from NursingCEU.com:
http://www.nursingceu.com/courses/301/index_nceu.html
Leifer, D., Bravata, D. M., Connors III, J., Hinchey, J. A., Jauch, E. C., Johnston, S. C., et al. (2011). Metrics for
Measuring Quality of Care in Comprehensive Stroke Centers: Detailed Follow-Up to a Brain Attack Coalition
Comprehensive Stroke Center Recommendations: A Statement for Healthcare Professionals From the American
Heart Association. Stroke: Journal of the American Heart Association (online) , 1-29.
Otwell, J. L., Phillippe, H. M., & Dixon, K. S. (2010). Efficacy and Safety of IV Alteplase Therapy Up to 4.5 Hours After
Acute Ischemic Stroke Onset. American Journal of Health-System Pharmacists , 1070-1074.
Outcome Sciences Inc. (2011). The Outcome System. Retrieved July 10th, 2012, from https://qi.outcome.com
Saver, J. L., Smith, E. E., Fonarow, G. C., Reeves, M. J., Zhao, X., Olson, D. M., et al. (2010). The “Golden Hour” and Acute Brain
Ischemia. Stroke: Journal of The American Heart Association , 1431-1439.
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