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IOWA STROKE PERFORMANCE IMPROVEMENT Toolkit Created in collaboration with the Minnesota Stroke Registry and the Minnesota Department of Health

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Iowa Stroke Performance ImProvement Toolkit

Created in collaboration with the Minnesota Stroke Registry and the Minnesota Department of Health

Iowa Stroke Performance Improvement Toolkit

Performance Measure Descriptions.Page 3 Hospital Readiness................................Page 4 STK 1..........................................................Page 9 STK 2..........................................................Page 12 STK 3..........................................................Page 13 STK 4..........................................................Page 15 STK 5..........................................................Page 20 STK 6..........................................................Page 22 STK 7..........................................................Page 24 STK 8.......................................................................Page 28 STK 9..........................................................Page 32 STK 10........................................................Page 36

Purpose of the Toolkit The purpose of the Stroke Performance Improvement Tool-kit is to provide the steps and strategies needed to address the quality measures within a hospitals stroke program. The toolkit’s target audience is rural hospitals. But any hospital may find the toolkit useful as they develop their stroke program.

Table of ConTenTs

Page 2

Questions or Comments For questions or comments about the Performance Improvement Toolkit, please contact Ellyn Cowan at [email protected]

PerformanCe measure DesCriPTions

STK-5: Patients with ischemic stroke who receive antithrombotic therapy by the end of hospital day two

STK-6: Ischemic stroke patients with LDL >100, or LDL not measured, or, who were on cholesterol reducing therapy prior to hospitalization are discharged on statin medication.

STK-7: Patients with ischemic or hemorrhagic stroke who undergo screening for dysphagia with an evidence-based bedside testing protocol before being given any food, fluids, or medication by mouth

STK-8: Patients with ischemic or hemorrhagic stroke or their caregivers who were given educational materials during the hospital stay addressing all of the following: risk factors for stroke, warning signs for stroke, activation of emergency medical system, the need for follow-up after discharge, and medications prescribed at discharge.

STK-9: Patients with ischemic or hemorrhagic stroke with a history of smoking cigarettes, who are, or whose caregivers are, given smoking cessation advice or counseling during hospital stay. (For the purposes of this measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival.

STK-10: Patients with an ischemic stroke or hemorrhagic stroke who were assessed for rehabilitation services.

AHA American Heart Association CT Computed tomographyED Emergency DepartmentEHR Electronic Health Record FTE Full time equivalentICH Intracerebral hemorrhageISR Iowa Stroke Registry IT Information Technology IV IntravenousLDL Low density lipoproteinNPO nil per os (nothing by mouth)OT Occupational therapyPDSA Plan-Do-Study-ActPT Physical therapyQI Quality ImprovementSLP Speech-Language PathologistsTIA Transient Ischemic AttacktPA Tissue plasminogen activatorVTE Venous thromboembolism

abbreviaTions

Page 3

STK-1 : Patients with an ischemic stroke or a hemorrhagic stroke who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission.

STK-2: Patients with an ischemic stroke prescribed antithrombotic therapy at discharge.

STK-3: Patients with an ischemic stroke with atrial fibrillation/flutter discharged on anticoagulation therapy. STK-4: Acute ischemic stroke patients who arrive at the hospital within 120 minutes (2 hours) of time last known well and for whom IV tPA was initiated at this hospital within 180 minutes (3 hours) of time last known well.

Iowa Stroke Performance Improvement Toolkit

HosPiTal reaDiness Administrative Organizational Support Strategies for Implementation

The hospital administration must be committed to providing resources, financial and human, to the development and implementation of a stroke program.

The length of time to develop a stroke program can vary. Factors such as administrative support, staffing, and financial resources can affect the time it takes to develop a program.

Obtain hospital Board commitment to the stroke program.

Include the stroke program as part of the hospitals strategic plan.

Talking points for why a stroke program is important:1. Shorter length of stay2. Cost savings3. Certification4. Public reporting5. To improve stroke outcomes (Share a

patient’s story)

Primary Staff Affected/Involved• Administrators • Managers

Resources• http://www.mnstrokeregistry.

org/documents/Sample_Pa-tient_Flow.pdf

• http://www.mnstrokeregistry.org/documents/Stroke_Checklist_1_Quality.pdf

• http://www.mnstrokeregistry.org/documents/Stroke_Checklist_2_EMS_ED_Pro-cesses.pdf

• http://www.mnstrokeregistry.org/documents/Stroke_Checklist_3_Inpatient_Pro-cesses.pdf

• http://www.mnstrokeregistry.org/documents/Stroke_Checklist_4_Sustaining_Gains.pdf

Page 4

noTes:

Iowa Stroke Performance Improvement Toolkit

Commitment to Quality Improvement Strategies for Implementation

Primary Staff Affected/Involved• Administrators• Managers• Quality Department

Have in place a documented system for ongoing quality improvement (QI) that demonstrates acting on evidence-based guidelines/practices. It may be helpful to work with the quality department staff to ensure that stroke care is included in the hospital’s QI efforts.

HosPital Readiness Continued - Page 5

Designated Stroke Coordinator Strategies for Implementation

Identify/hire a stroke coordinator to: • Coordinate hospital care• Lead the effort to implement the stroke performance

measures• Build relationships: the stroke coordinator should

foster relationships with ED, IT, QI, Human resources, and marketing and research staff and educate them on why stroke care is important

• Present performance data to management: data sources could include ISR reports if a participant in the stroke registry or chart audits.

• Be involved in quality improvement initiatives.

Determine FTE. FTE assigned to the role will vary byhospital. It could be based on the annual stroke volume or the amount of time the coordinator will spend on direct care and indirect care. Stroke Coordinator to participate in the Stroke Coordinator Consortium

Primary Staff Affected/Involved• Administrators• Nurse Managers• Nursing

ResourcesDesignated Stroke Coordinator Resources: Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Stroke Patient, AHA: http://stroke.ahajournals.org/con-tent/40/8/2911.full.pdf

Guide to the Care of the Hospitalized Patient with Ischemic Stroke, 2nd Edition: http://www.aann.org/pdf/cpg/aannischemicstroke.pdf

Stroke Coordinator Job Description Examples, AHA: http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuide-linesHFStroke/Best-Practices-Center-Stroke_UCM_305500_Article.jsp

Commitment to Quality Improvement Resources: Improvement Resources, Institute for Healthcare Improvement: http://www.ihi.org/Pages/default.aspx

Iowa Stroke Coordinator Consortium Contact: Erin Rindels at [email protected]

Iowa Stroke Performance Improvement Toolkit

Multidisciplinary Stroke Committee Strategies for Implementation

Develop a multidisciplinary stroke committee• The multidisciplinary stroke committee is

responsible for providing vision and direction for stroke care within the hospital.

• The committee may be coordinated by the Stroke Coordinator, QI staff, a physician, or other interested staff members

• Identify a physician champion. Studies show having a highly engaged physician champion is key to a successful program.

• Committee members could include representatives from:

• Nursing• Emergency department• Medical• Pharmacy• Stroke related therapies (SLP, PT, OT, Rehab)• Quality Department• IT

• Meeting frequency• How often the team meets will vary by hospital.

Some teams meet monthly while other meet quarterly. If a program is new, more frequent meetings may be necessary with the schedule adjusted as the program matures.

HosPiTal reaDiness

HosPital Readiness Continued - Page 6

Meeting agendas• Meeting agendas can be

prepared by the coordinator. If a program is new, agenda items may first focus on establishing team responsibilities and program planning (identify strengths and gaps in stroke care). As the program matures, the focus may shift to quality improvement activities.

noTes:

Activities the stroke team may undertake: • Conduct an assessment of the stroke program. • Identify strengths and gaps of the stroke program based on

review of the data. • Review and research current guidelines and best practices • Develop policies and procedures to guide the stroke pro-

gram based on current guidelines and best practices. • Review stroke algorithms, pathways, order sets,

- If not in place or they need revisions, this could be a starting place for the team quality improvement activities

• Develop a work plan to track activities, responsibilities, and timelines.

Review data on a regular basis • How frequently the data is reviewed will vary by hospital.

Weekly, monthly, or quarterly reviews are completed de-pending on the number of stroke patients and when the team meets.

• Work with the Iowa Stroke Registry for detailed reports

Develop and implement quality improvement interventions• Identify QI method for evaluating the implementation of the

performance measures (e. g. PDSA)- Start small; do not try to develop and implement all the measures at once.

• Use data to guide process. • The hospitals quality department or the Iowa Healthcare

Collaborative QI lead can be contacted for assistance

Acknowledge milestones and achievements of those involved in the stroke program • Post kudos in the break room, report room, or locker room

Iowa Stroke Performance Improvement Toolkit

Primary Staff Affected/Involved• Nursing• Emergency Department• Medical• SLP• PT• OT• Quality Department• IT

HosPital Readiness Continued - Page 7

Report to the hospital Board on a regular basis, at least annually.

Multidisciplinary Stroke Committee Strategies for Implementation

ResourcesIowa Stroke Registry http://www.idph.state.ia.us/ems/common/pdf/stroke_rational.pdf

Team Meeting Tools, AHAhttp://www.heart.org/HEARTORG/HealthcareResearch/GetWithThe-GuidelinesHFStroke/GetWithTheGuidelinesStrokeHomePage/Get-With-The-Guidelines-Stroke-Toolbox_UCM_308030_Article.jsp

Best Practices Center, Stroke, AHAhttp://www.heart.org/HEARTORG/HealthcareResearch/GetWithThe-GuidelinesHFStroke/Best-Practices-Center-Stroke_UCM_305500_Article.jsp

Iowa Stroke Performance Improvement Toolkit

Success Story HosPiTal reaDiness

WHAT IS YOUR STORY?

HosPital Readiness Continued - Page 8

Organizational VTE Policy Strategies for Implementation

sTK - 1 venous THromboembolism

(vTe) ProPHylaxis

Iowa Stroke Performance Improvement Toolkit

Establish organization policy for VTE, inclusive of stroke care • Policy at the organizational level signals a

commitment to quality and accountability to the care practices

• Align your policy with the meaningful use expectations

• Align your policy with quality measures and safety goals

Designate a multidisciplinary team to address VTE prevention, diagnosis, and treatment

Have in place a documented system for ongoing QI that demonstrates acting on evidence-based guidelines/practices

Develop system for training and education on VTE policy

Primary Staff Affected/Involved• Administrators • Managers• Physicians• Stroke Coordinator• Quality and Safety Staff

Page 9

noTes: ResourcesAgency for Healthcare Research and Quality (AHRQ)http://www.ahrq.gov/profession-als/quality-patient-safety/patient-safety-resources/resources/vtguide/index.html

National Quality Forum (NQF)http://www.qualityforum.org/Home.aspx

Society of Hospital Medicinehttp://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Ve-nous_Thromboembolism/Web/Quality___Innovation/Implemen-tation_Toolkit/Venous/Overview.aspx

Iowa Stroke Performance Improvement Toolkit

stK 1 Continued - Page 10

Patient Education Strategies for Implementation

Develop a system for providing patient/caregiver education for inpatients. Items to consider include:

• Risk of VTE• Importance of VTE prophylaxis• Correct use of VTE prophylaxis• Potential adverse drug reactions or interactions• How to reduce the risk of VTE

Develop a system for providing education for patients discharged on VTE prophylaxis. Include documentation of:

• The patient’s own awareness of their risk for VTE• Signs and symptoms of VTE• Activity Level• When to seek treatment• Understanding of the prescribed

anticoagulation regimen

Maintain a list of patient education materials to use• The written information that is given to the patient and/or • caregiver will vary by hospital. Some hospitals use materials that

are developed in house, while others order materials from various vendors.

Primary Staff Affected/Involved• Nurses

sTK - 1 venous THromboembolism

(vTe) ProPHylaxis

noTes:

VTE Protocol Strategies for Implementation

Utilize evidence-based guidelines for developing the VTE protocol

Examine existing stroke admission order set and transfer order sets for inclusion of VTE prophylaxis

Embed the VTE protocol guidance into the stroke admission order set

Primary Staff Affected/Involved• Administrators • Managers• Physicians• Stroke Coordinator• Quality and Safety Staff

Iowa Stroke Performance Improvement Toolkit

stK 1 Continued - Page 11

Resourceshttp://www.mnstrokeregistry.org/documents/DVT_Protocol_LifeC-are_Medical_Center.pdf

https://www.icsi.org/guidelines__more/

IHC VTE Toolkithttp://www.ihconline.org/aspx/general/page.aspx?pid=137

VTE Documentation Strategies for Implementation

Documentation should include: • The date antithrombotic therapy was initiated

• Antithrombotic therapy should be initiated the day of or the day after hospital admission

• The type of VTE prophylaxis provided• The reason(s) why antithrombotic therapy was not

administered the day of or the day after hospital admission

• If the patient was ambulating on the day of admission or the day after admission

Provide feedback to providers in real time

Primary Staff Affected/Involved• Nurses

Questions or Comments For questions or comments about the Performance Improvement Toolkit, please contact Ellyn Cowan at [email protected]

Iowa Stroke Performance Improvement Toolkit

Patient Stroke Education Strategies for Implementation

A standardized procedure for patient stroke education should be developed (See stroke education performance measure)

The procedure should include the element medications Prescribed at discharge. Antithrombotic medications are Included in this element.

Primary Staff Affected/Involved• Nurses

Discharge Order Set Strategies for Implementation

A standardized discharge order set for stroke should be developed that includes, under the medications section, antithrombotic therapy.

Utilize best practices for prescribing the anti-thrombotic

Develop a list of antithrombotic medications within the EHR as a prompt The discharge order set should include documentation that an antithrombotic was prescribed and if not prescribed the contraindications could be listed as a prompt for documentation

Primary Staff Affected/Involved• Physicians• Nurses

Page 12

sTK - 2 DisCHargeD on

anTiTHromboTiC THeraPy

ResourcesDischarge order set examples, AHAhttp://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuide-linesHFStroke/GetWithTheGuideli-nesStrokeHomePage/Get-With-The-Guide-lines-Stroke-Toolbox_UCM_308030_Article.jsp

noTes:

Iowa Stroke Performance Improvement Toolkit

sTK - 3 PaTienTs wiTH aTrial fibrillaTion/

fluTTer reCeiving anTi-CoagulaTion THeraPy

Admission Order Set Strategies for Implementation

A standardized admission order set for stroke should be developed that includes anticoagulation therapy for atrial fibrillation or flutter. Evidence-based guidelines should be used to develop the admission order set.

Primary Staff Affected/Involved• Physicians• Nurses

Admission Assessment Strategies for Implementation

The admission assessment should include a question about the patient’s medical history of atrial fibrillation or flutter and medications for atrialfibrillation or flutter prior to admission.

Documentation should include any history of atrial fibrillation or flutter or present atrial fibrillation or flutter.

• Nurses

Page 13

Primary Staff Affected/Involved

noTes:

ResourcesOrder set examples, AHA:http://www.heart.org/HEARTORG/HealthcareResearch/GetWith-TheGuidelinesHFStroke/GetWithTheGuidelinesStroke-HomePage/Stroke-Clinical-Tools-Li-brary_UCM_303743_Article.jsp

Patient Stroke Education Strategies for Implementation

Iowa Stroke Performance Improvement Toolkit

Discharge Order Set Strategies for Implementation

A standardized discharge order set for stroke should be developed that includes, under the medications section, anticoagula-tion therapy for atrial fibrillation or flutter

Utilize best practices for prescribing the anticoagulation therapy.

• Develop a list of anticoagulation medications within the EHR as a prompt.

The discharge order set should include documentation that anticoagulation therapy was prescribed and if not prescribed the reason(s) why not.

• Contraindications could be listed as a prompt for documentation.

Primary Staff Affected/Involved• Nurses• Physicians

stK 3 Continued - Page 14

sTK - 3 PaTienTs wiTH aTrial fibrillaTion/

fluTTer reCeiving anTi-CoagulaTion THeraPy

A standardized procedure for patient stroke education should be developed (See stroke education performance measure.

The procedure should include the element medications prescribed at discharge. Anticoagulation therapy for atrial fibrillation or flutter is included in this element.

Primary Staff Affected/Involved• Nurses• Physicians

ResourcesDischarge order set examples, AHA• http://www.heart.org/HEARTORG/

HealthcareResearch/GetWith-TheGuidelinesHFStroke/GetWith-TheGuidelinesStrokeHomePage/Get-With-The-Guidelines-Stroke-Toolbox_UCM_308030_Article.jsp

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Iowa Stroke Performance Improvement Toolkit

sTK - 4 THrombolyTiC THeraPy aDminisTereD

Background Information on tPA Strategies for Implementation

Provide staff, such as ED physicians, ED nurses, and neurologists, with the historical and current research for tPA.

Education sessions could be developed that focus on the benefits of tPA and how to develop pathways and order sets.

Resources - Literature

Primary Staff Affected/Involved• ED physicians• ED nurses• Neurologists• Stroke Coordinator

Page 15

• AHA Guidelines for the Early Management of Adults with Ischemic Stroke, 2007 http://stroke.ahajournals.org/content/38/5/1655.full.pdf

• Thromboloysis with Alteplase 3 to 4.5 Hours After Acute Ischemic Stroke, 2008 http://www.nejm.org/doi/pdf/10.1056/NEJ-Moa0804656

• Expansion of the Time Window for Treat-ment of Acute Ischemic Stroke with Intrave-nous Tissue Plasminogen Activator http://stroke.ahajournals.org/content/40/8/2945.full.pdf+html

noTes: Resources - Continued• Legal Aspects of Acute Stroke, Presentation

by Dr. Justin Zivin, San Diego Medical Cen-ter, May 26, 2010 http://www.health.state.mn.us/divs/ hpcd/chp/cvh/pdfs/toolLEGAL-stroke.pdf

• Ischemic stroke guideline, ICSI, 2012. https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_cardiovascular_guidelines/stroke/

• Timelines of Tissue-Type Plasminogen Ac-tivator Therapy in Acute Ischemic Stroke Patient Characteristics, Hospital Factors, and Outcomes Associated with Door-to-Needle Times Within 60 Minutes, 2011 http://circ.ahajournals.org/content/early/2011/02/10/CIRCULATIONAHA.110.974675.full.pdf+html

• Outcome by Stroke Etiology in Patients Re-ceiving Thrombolytic Treatment: Descriptive Subtype Analysis, 2011: http://stroke.ahajour-nals.org/content/42/1/102.full.pdf+html

Iowa Stroke Performance Improvement Toolkit

ED Triage Protocol Strategies for Implementation

A triage protocol is necessary to: • Quickly assess patients for possible

stroke,• Determine the type and severity of the

stroke,• Treat it quickly, or• Have the patient transported to a

receiving hospital (treat/stabilize and transfer)

The stroke team and acute stroke pathway should be activated as soon as a strokepatient is identified.

Primary Staff Affected/Involved• ED physicians• ED nurses• ED unit coordinators

Page 16

sTK - 4 THrombolyTiC THeraPy aDminisTereD

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Develop Documentation Process Strategies for Implementation

Develop a process to document pre-hospital information, ED care and treatments. • Within the EHR• Paper and kept in chart

Work with IT and the stroke committee to update or implement documentation within the EHR

• ED physicians• ED nurses• ED unit coordinators • IT department• Quality department

Primary Staff Affected/Involved

Questions or Comments For questions or comments about the Performance Improvement Toolkit, please contact Ellyn Cowan at [email protected]

Acute Stroke Pathway Strategies for Implementation

The pathway should expedite the evaluation and treatment of patients eligible for tPA.

Elements of the pathway should include: • Pre-hospital information• Time to treatments• Tests and procedures• Nursing interventions• Physician orders• Medications

Evidence-based guidelines should be used to develop the acute stroke pathway.

Primary Staff Affected/Involved• ED physicians• ED nurses• ED unit coordinators• Laboratory staff• Radiology staff • Pharmacy Staff

Iowa Stroke Performance Improvement Toolkit

Door-to-needle Time Strategies for Implementation

Benchmark times should be established for evaluation and treatment such as:

• Door to initial exam in ED 10 minutes• Door to CT 25 minutes• Door to CT/Lab results 45 minutes• Door to tPA 60 minutes

Primary Staff Affected/Involved• ED physicians• ED nurses• ED unit coordinators

stK 4 Continued - Page 17

Resources• Target: Stroke Clinical Tools, AHA http://www.stroke-

association.org/STROKEORG/Professionals/Target-Stroke_UCM_314495_SubHomePage.jsp

• Target: Stroke Patient Time Tracker http://www.strokeassociation.org/idc/groups/heart-public/@wcm/@hcm/@gwtg/documents/downloadable/ucm_309007.pdf

Resources• Examples of pathways, AHA http://www.heart.org/

HEARTORG/HealthcareResearch/GetWithTheGuide-linesHFStroke/GetWithTheGuidelinesStrokeHomePage/Stroke-Clinical-Tools-Library_UCM_303743_Article.jsp

• Preliminary evaluation, BAC http://www.stroke-site.org/or-ders/edo_setone.pdf

Develop Documentation Process Strategies for Implementation

• ED physicians• ED nurses• ED unit coordinators • IT department• Quality department

Primary Staff Affected/Involved

tPA Orders Strategies for Implementation

Iowa Stroke Performance Improvement Toolkit

stK 4 Continued - Page 18

Admission Orders Strategies for Implementation

Admission orders should be developed for patient’s post-tPA

Primary Staff Affected/Involved• ED manager• Inpatient manager• Nurses• Physicians

Standing orders for tPA should be developed

Elements of the standing orders should include:• Patient eligibility criteria• Contraindications• Medication administration• Blood pressure management• Suspected ICH management

The risks and benefits of tPA should be explained to the patient and/or care giver. This should be documented in the patient’s chart.

Primary Staff Affected/Involved• ED physicians• ED nurses• Pharmacy

sTK - 4 THrombolyTiC THeraPy aDminisTereD

noTes:

Resources• tPA Checklist, BAC http://www.

stroke-site.org/pathways/rtpa_checklist.pdf

Resources

ED Nurse Interventions Strategies for Implementation

Nursing interventions should be incorporated into the acute stroke pathway and tPA standing orders.

Primary Staff Affected/Involved• ED nurses

ED Physician Orders Strategies for Implementation

Physician orders should be incorporated into the acute stroke pathway and tPA standing orders.

Primary Staff Affected/Involved• ED physicians

Iowa Stroke Performance Improvement Toolkit

stK 4 Continued - Page 19

Resources

Transfer Protocol Strategies for Implementation

Nursing interventions should be incorporated into the acute stroke pathway and tPA standing orders.

Establish a relationship with the receiving hospital.

Primary Staff Affected/Involved• ED manager• Nurses• ED physician

• Transfer questionnaire, Montana Stroke Initiative http://www.montanastroke.org/Protocols.htm

Resources• Physician orders, BAC http://www.stroke-site.org/orders/

edo_settwo.pdf

• ED Nursing orders UMICH tPA Packet, 2011 http://www.health.state.mn.us/divs/hpcd/chp/cvh/pdfs/toolUMICH-trtmt2011.pdf

Iowa Stroke Performance Improvement Toolkit

sTK - 5 anTiTHromboTiC THeraPy by enD of HosPiTal Day Two

Admission Order Set Strategies for Implementation

A standardized admission order set for stroke should be developed that includes antithrombotic therapy for early secondary prevention. • The standing order should state when to initiate

antithrombotic therapy. For example, if tPA was administered it should state not to begin anti-thrombotic therapy within 24 hours of completing tPA administration.

• Anticoagulants at doses to prevent deep vein thrombosis are insufficient antithrombotic therapy to prevent recurrent ischemic stroke or TIA

Documentation should clearly state that anithrombotic therapy was initiated by the end of the hospital day two. • “Hospital day two” for this measure is the day after

patient arrival. Arrival date and admission date may not always be the same.

• If antithrombotic therapy was not initiated by the end of the hospital day two, the reason(s) should be documented in the patient’s medical record.

Evidence-based guidelines should be used to develop the admission order set.

Primary Staff Affected/Involved• Physicians• Nurses

Page 20

Resources• Order set examples, AHA:

http://www.heart.org/HEARTORG/HealthcareRe-search/GetWithTheGuide-linesHFStroke/GetWithThe-GuidelinesStrokeHomePage/Stroke-Clinical-Tools-Library_UCM_303743_Article.jsp

noTes:

Admission Assessment Strategies for Implementation

The admission assessment should include a question about the patient’s medical history of antithrombotic therapy prior to admission.

As part of the medication reconciliation, documentation should include anti-thrombotic medications priorto admission.

Primary Staff Affected/Involved• Nurses

Iowa Stroke Performance Improvement Toolkit

stK 5 Continued - Page 21

Questions or Comments For questions or comments about the Performance Improvement Toolkit, please contact Ellyn Cowan at [email protected]

Stroke Stroke

Stroke

Stroke

Stroke

Stroke

Stroke Stroke

Stroke Stroke Stroke

Disease

Disease

Assessment Assessment

Assessment Assessment

Assessm

ent A

ssessment

Education

EducationEducation

Education

Care

CareCare

Care

Care

Improvement

Improvement

Improvement

Improvem

ent

Improvem

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Patient

Patient

Patient

PatientPatient

PatientStroke

Education

Education

Assessm

ent

Iowa Stroke Performance Improvement Toolkit

sTK - 6 DisCHargeD on sTaTin meDiCaTion

Admission Order Set Strategies for Implementation

A standardized admission order set for stroke should be developed that includes information related to cholesterol levels and cholesterol medications • For example, under the Labs section, include

fasting lipid profile within 48 hours of admission (or include a place to document lipid panel results completed within 30 days prior to admit).

Evidence-based guidelines should be used to develop the admission order set.

Primary Staff Affected/Involved• Physicians• Nurses

Page 22

Resources• Order set examples,

AHA http://www.heart.org/HEARTORG/HealthcareRe-search/GetWithTheGuide-linesHFStroke/GetWithThe-GuidelinesStrokeHomePage/Stroke-Clinical-Tools-Library_UCM_303743_Article.jsp

noTes:

Admission Assessment Strategies for Implementation

The admission assessment should include a question about the patient’s medical history of dyslipidemia and medications for dyslipidemia prior to admission.

Primary Staff Affected/Involved• Nurses

Patient Stroke Education Strategies for Implementation

A standardized procedure for patient stroke education should be developed (see STK-8 Stroke Education)

The procedure should include the element medications prescribed at discharge. Statins or other cholesterol medications are included in this element.

Primary Staff Affected/Involved• Nurses

Iowa Stroke Performance Improvement Toolkit

Resources

Discharge Order Set Strategies for Implementation

A standardized discharge order set for stroke should be developed that includes, under the medications section, statins or other cholesterol medications prescribed for cholesterol reduction/control.

The discharge order set should include documentation that a statin was prescribed and if not prescribed, the reason(s) why not. This information should be included if other cholesterol medications are prescribed, or not. • Contraindications could be listed as a prompt

for documentation

Primary Staff Affected/Involved• Physicians• Nurses

stK 6 Continued - Page 23

• Discharge orders LDL specific, AHA: http://www.heart.org/HEARTORG/HealthcareResearch/GetWithThe-GuidelinesHFStroke/GetWithTheGuidelinesStroke-HomePage/Stroke-Clinical-Tools-Library_UCM_303743_Article.jsp

Iowa Stroke Performance Improvement Toolkit

sTK - 7 DysPHagia sCreening

Primary Staff Affected/Involved• Nurse Managers • Stroke Coordinator • SLP/OT

Dysphagia Screening Policy Strategies for Implementation

Develop a dysphagia screening policy• The policy should state who is screened, who

completes the screening, and what to do if a patient fails.

• It should state that the patient should be kept NPO in the Emergency Department, including medications, and on the unit until the screening is completed.

• Nursing and Speech Language Pathology (SLP) should work collaboratively to develop the dysphagia screening policy.

Sample Policy: • The dysphagia screening will be performed by an RN

who has received instruction and demonstrated competency in nursing dysphagia screening. All patients diagnosed with stroke or possible stroke will have a dysphagia screen performed prior to oral intake including medications. For patients who fail the dysphagia screen, SLP will be consulted for further evaluation and recommendations. The patient will remain NPO, including medications, until a bedside evaluation is performed by SLP.

• All stroke or possible stroke patients will be NPO in the ED, including medications.

Page 24

Resources• Implementing a Regional

Dysphagia Management Strategy, Heart and Stroke Foundation of Ontario http://www.heartandstroke.on.ca/atf/cf/%7B33C6FA68-B56B-4760-ABC6-D85B2D02EE71%7D/Dysphagia%20Tips%20Booklet%2002282005%20FINAL%5B1%5D.pdf

• Care of the Dysphagia patient protocol example, AHA http://www.heart.org/HEARTORG/HealthcareResearch/GetWith-TheGuidelinesHFStroke/Best-Practices-Center-Stroke_UCM_305500_Article.jsp

• NPO posters, Minnesota Stroke Registry http://www.mnstrokeregistry.org/qi.html

noTes:

Iowa Stroke Performance Improvement Toolkit

Dysphagia Screening Procedure Strategies for Implementation

Develop a dysphagia screening procedure• The procedure should include an evidence-based swallow

screen tool. • The procedure should list the necessary steps to complete

the screening. • The procedure should be located in a convenient location so

it can be used as a reference for the nursing staff.

Nursing and SLP should work collaboratively to develop the procedure.

Primary Staff Affected/Involved• Nurse Managers • Stroke Coordinator• Staff RNs• SLP/OT

Utilize an Evidence-based Screening Tool Strategies for Implementation

Choosing an evidence-based swallow screen tool. • Complete a literature review of swallow screens• Collaborate with SLP to test one or two tools to determine

which one is the most appropriate for the hospital.

Assessing a swallow screen in use

Nursing and SLP should work collaboratively to choose or assess the swallow screen

Primary Staff Affected/Involved• Stroke Coordinator• SLP/OT• Staff RNs

stK 7 Continued - Page 25

Resources• Dysphagia screening tools, AHA. http://www.heart.org/

HEARTORG/HealthcareResearch/GetWithTheGuide-linesHFStroke/GetWithTheGuidelinesStrokeHomePage/Stroke-Clinical-Tools-Library_UCM_303743_Article.jsp#

• TOR-BSST Swallow Screen http://swallowinglab.com/tor-bsst/

• Assessing Your Swallow Screen http://www.health.state.mn.us/divs/hpcd/chp/cvh/pdfs/toolGLRSNSwllw2009.pdf

Iowa Stroke Performance Improvement Toolkit

Nurse Education Strategies for Implementation

Ideally, the nursing education should be a collaboration between SLP and Nursing.

The education should demonstrate competency in use of the screening tool through direct observation and teach back methods. It should also include information on the signs of dysphagia, behavioral observations, and observation of eating and drinking.

Which RNs are educated will vary by hospital • Should all RNs be educated or a core group?• Should full time RN staff be educated first and then

part-time staff?

Education Schedule • An education schedule should be developed. When

education takes place may depend on which RNs are being educated. New nurses may be educated during hospital or unit orientation. Current RNs could be educated during the hospitals annual competency testing.

• Annual refresher education should be offered. This should include a competency requirement.

The GLRSN has developed a checklist “Assessing Your Swallow Screen Training” to determine if it meets best practice guidelines [checklist in resources].

Primary Staff Affected/Involved• Stroke Coordinator• Nursing Education• Staff RNs • SLP/OT

Resources• Dysphagia Screen Skills

Checklist Example, AHA http://www.heart.org/HEARTORG/HealthcareResearch/GetWith-TheGuidelinesHFStroke/Best-Practices-Center-Stroke_UCM_305500_Article.jsp

• Assessing Your Dysphagia Training, GLRSN http://www.health.state.mn.us/divs/hpcd/chp/cvh/pdfs/toolGLRSN-dysph.pdf

sTK - 7 DysPHagia sCreening

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stK 7 Continued - Page 26

Iowa Stroke Performance Improvement Toolkit

Resources

Documentation Process Strategies for Implementation

Paper• Attach the swallow screen to the nursing worksheets or

admission assessment. • On the order set, have it state that patient must be NPO until

dysphagia screening is completed.

Electronic• Triggered directly from the admission assessment• Do not allow diet order to be submitted until the screen is

completed • Have paper copies available

Primary Staff Affected/Involved• Nurse Manager• Stroke Coordinator• SLP/OT• IT Department • Discharge Planners• Admission Staff• Bed Manager

Work with IT and other staff to incorporate the dysphagia screening tool and documentation in the EHR if using electronic record. • Issue to consider:

How does the change affect other documentation processes (if changed for stroke how does that affect documentation for other units, i. e. OB)?

SLP Evaluation for Failed Screen Strategies for Implementation

Develop a protocol for SLP evaluation for patients that fail the dysphagia screen.

If a hospital has SLP services 24/7 an evaluation can be ordered and completed when needed.

If a hospital has limited SLP services, such as weekday coverage only, a plan should be in place to address the patient’s care.

Primary Staff Affected/Involved• Staff RNs• SLP/OT

• Dysphagia Screen Within Order Sets, AHA http://www.heart.org/HEARTORG/HealthcareResearch/GetWith-TheGuidelinesHFStroke/GetWithTheGuidelinesStroke-HomePage/Stroke-Clinical-Tools-Library_UCM_303743_Article.jsp

stK 7 Continued - Page 27

Questions or Comments For questions or comments about the Performance Improvement Toolkit, please contact Ellyn Cowan at [email protected]

Iowa Stroke Performance Improvement Toolkit

sTK - 8 sTroKe eDuCaTion

Stroke Education Policy Strategies for Implementation

Develop a stroke education policy: • Who completes the stroke education,• When is stroke education completed,• How is stroke education documented.

Review the policy annually and revise as necessary

Primary Staff Affected/Involved• Nurse Managers• Stroke Coordinator• SLP/OT/PT

Sample Policy: Stroke education is completed for all patients with ischemic or hemorrhagic stroke or their caregivers before the patient is discharged from the hospital. Stroke education is completed by nurses who have completed education on stroke education. Stroke education is documented on the stroke education teaching care plan within the EHR.

Develop Documentation Process Strategies for Implementation

Document stroke education• Within the EHR• Paper and kept in chart

Work with IT and other staff to incorporate documentation of stroke education within the EHR.

Develop a poster that tells how to document patient stroke education. Place posters near the computers or charting area.

Primary Staff Affected/Involved• Nurse Manager• Stroke Coordinator• IT Staff• Discharge Planners• Admission Staff • Bed Manager• SLP/OT/PT

Issue to consider: How does the change affect other documentation processes (if changed for stroke how does that affect patient education documentation for other units, I.e. OB)?

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Iowa Stroke Performance Improvement Toolkit

Stroke Education Procedure Strategies for Implementation

Develop a stroke education teaching care plan • The teaching care plan outlines what information should be

covered on each day• The teaching care plan can be a paper document that is kept

by the bedside or embedded in the EHR. It is used to document what teaching has been completed and by whom.

• The teaching care plan can be in the form of a checklist. • The teaching care plan should include all five elements of the

performance measure: risk factors for stroke, warning signs for stroke, activiation of emergency medical system, the need for follow-up after discharge, and medications prescribed at discharge.

• The “teach back” method can be considered as one patient education method.

• The teaching care plan could include what materials to use

How to document stroke education should be included in the procedure• If specific stroke orders are being used, stroke education

should be included within the orders. • If specific stroke orders are not being used the teaching care

plan can be placed with the admission form for the nurses’ use.

A standardized discharge order set should be developed that includes the five elements of patient stroke education

Review the procedure annually and revise as necessary

Primary Staff Affected/Involved• Nurse Managers• Stroke Coordinator • SLP/OT/PT

Resources• Patient Education Materials, GLRSN http://www.health.

state.mn.us/divs/hpcd/chp/cvh/pdfs/toolGLRSNpatient-edu.pdf

• Patient Education/Discharge Orders, AHA http://www.heart.org/HEARTORG/HealthcareResearch/GetWith-TheGuidelinesHFStroke/GetWithTheGuidelinesStroke-HomePage/Stroke-Clinical-Tools-Library_UCM_303743_Article.jsp

stK 8 Continued - Page 29

Iowa Stroke Performance Improvement Toolkit

Nurse Education on Stroke Education Strategies for Implementation

Develop an education plan: 1. Identify who needs the education• Start Small; educate one or two nurses or one unit at a time• Conduct PDSA cycle to gather information and made revisions to the education before

expanding to more nurses or units. A PDSA cycle does not have to be complicated or formal. It can be as simple as gathering feedback from one or two people.

2. When to educate new hires3. Include as part of nurses annual competency testing4. Retraining/refresher methods: as part of annual competency testing, information in

newsletter, email blasts

Develop stroke education training module • Paper or online format• Materials to be used: can include information on the required five elements, a copy of

the teaching care plan, what patient education materials are used, how stroke patient education is initiated, and information on how to document the patient education

Review the procedure annually and revise as necessary

Issue to consider: If there is limited or no budget for nursing education• Nurse education can still happen with a limited budget• Only educate the nurses on the unit where the majority of stroke patients are admitted • Place education materials in a location where the nurses will see them, such as the

report area • Have the nurse complete a post test after reviewing the materials to help ensure

understanding of the material • Place posters or the reminders around the unit with information on completing and

documenting patient education

• Stroke Coordinator• Nursing Education• Staff RNs• SLP/OT/PT

Primary Staff Affected/Involved

sTK - 8 sTroKe eDuCaTion

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stK 8 Continued - Page 30

Iowa Stroke Performance Improvement Toolkit

Stroke Patient Education Materials Strategies for Implementation

Standardize education materials1. Develop a review process and criteria for selecting materials

• Materials should meet plain language/health literacy standards

• Materials should address all five elements: risk factors for stroke, warning signs for stroke, activation of emergency medical system, the need for follow-up after discharge, and medications prescribed at discharge.

2. Identify who should be involved in the selection and review process such as communications staff.

3. Develop schedule for reviewing the materials to assure they meet the education needs of the patients.

Maintain a list of education materials to use • The written information that is given to the patient and/or

caregiver will vary by hospital. Some hospitals used materials that are developed in house, while others order materials from various vendors.

Have materials stocked in convenient locations on the unit• The placement of the materials on a unit is a decision made

by each hospital. A PDSA process may be used to determine the best location

Have a process for managing inventory and ordering materials

• Stroke Coordinator• Communications Staff • Staff RNs• SLP/OT/PT

Resources

Primary Staff Affected/Involved

• Minnesota Health Literacy Partnership http://healthliteracymn.org/

• AMA Foundation http://www.ama-assn.org/ama/pub/about-ama/ama-foundation/our-programs/public-health/health-litera-cy-program/health-literacy-kit.page

• The Harvard School of Public Health: Health Literacy Studies http://www.hsph.harvard.edu/healthliteracy/

• National Stroke Association http://www.stroke.org/we-can-help/survivors/stroke-recovery/first-steps-recovery/preventing-an-other-stroke?pagename=STARS

• Health Literacy http://www.ihconline.org/aspx/initiatives/health-literacy.aspx

stK 8 Continued - Page 31

Iowa Stroke Performance Improvement Toolkit

sTK - 9 smoKing CessaTion aDviCe

or Counseling

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Staff Education Strategies for Implementation

Provide educational opportunities to all healthcare professionals to detail the tobacco cessation program• Include as on component of new staff orientation• Incorporate into staff meetings• Utilize email for program updates and reminders

Provide educational opportunities to all healthcare professionals who will provide the tobacco use inter-vention (i.e. the 5 A’s). • Educational opportunities could include online

training or educational sessions develop in-house• Include as part of new staff orientation• Incorporate into the annual nurse

competency testing

Provide training on motivational interviewing for healthcare professionals• Motivational interviewing techniques can be sued

to assess patient readiness to quit

• Physicians • Nurses• Tobacco Cessation Specialists• Respiratory Therapy • OT• PT• Rehabilitation• Pharmacists

Primary Staff Affected/Involved

Resources• Motivational Interviewing

http://motivationalinterview.org/?reqp=1&reqr=nzcdYacuMzqyLaulMKW0qzMaMJjhLzI0

• American Academy of Fam-ily Physicians, Ask and Act Tobacco Cessation Program http://www.aafp.org/patient-care.html

• IHC Tobacco Cessation Toolkit http://www.ihconline.org/aspx/general/page.aspx?pid=18

Iowa Stroke Performance Improvement Toolkit

Develop a hospital-wide smoking cessation program • Utilize an interdisciplinary team to develop the program• Identify a physician champion to promote

cessation activities

Utilize an evidence-based tobacco use intervention, such as the 5 A’s (Ask, Advise, Assess, Assist, Arrange)

Utilize evidence-based guidelines for the development of tobacco use treatment pathways

Develop an evaluation plan to evaluate the program impact

Provide feedback to healthcare professionals. • Utilize data to show trends in provider advice/counseling,

referrals, and pharmacological therapy prescribed.

Align with core measures

Talking points for why a hospital-wide cessation program is important, include: • Patients may be motivated to quit if the hospitalization was

caused by or made worse due to tobacco use/smoking• For accreditation or certification requirements• To meet quality measures• Increase consistency in patient care • Improved health of the community

• Administration• Managers• Physicians• Nurses• Respiratory Therapists• Clinical Pharmacists• Tobacco Cessation Specialists• Quality Staff

Primary Staff Affected/Involved

Resources• Centers for Disease Control and Prevention, Smoking and Tobac-

co Use http://www.cdc.gov/tobacco/index.htm

• A Practical Guide to Working with Health-care Systems on Tobac-co-use Treatment http://www.cdc.gov/tobacco/quit_smoking/ces-sation/practical_guide/index.htm

• Agency for Healthcare Research and Quality (AHRQ) http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommen-dations/tobacco/index.html

• Healthcare Provider Reminder Systems, Provider Education, and Patient Education http://www.prevent.org/data/files/initiatives/to-baccousetreatment.pdf

• Helping Patients Quit: Implementing the Joint Commission To-baco Measure Set in Your Hospital http://www.prevent.org/data/files/resourcedocs/hpq,%20full,%20final,%2010-31-11.pdf

• UW-CTRI, Treating Tobacco Use and Dependence in Hospitalized Smokers http://www.ctri.wisc.edu/HC.Providers/healthcare.Hospi-tal.Packet.htm

Hospital-wide System to Address Smoking Cessation Strategies for Implementation

stK 9 Continued - Page 33

Iowa Stroke Performance Improvement Toolkit

Admission Order Set Strategies for Implementation

Develop a process to flag patient tobacco use status: never, former, and/or current.

Develop a documentation process: • Within the EHR to support and docu-

ment tobacco use intervention and treatment • Include a place to document that pa-

tient was asked about tobacco use• For a positive response, include a

place to document follow-up actions, such as referred to tobacco cessa-tion specialist or pharmacological therapy initiated

• Within the paper chart• Utilize a tracking form to keep with

the patient’s medical record

• Document within the progress note

• Managers• Nurses• IT Staff• Quality Staff

Primary Staff Affected/Involved

sTK - 9 smoKing CessaTion aDviCe

or Counseling

noTes: A standardized procedure for patient stroke education should be developed (See Stroke Education Performance Measure). • The procedure should include the

stroke education elements 1) risk factors for stroke and 2) medications prescribed at discharge • Smoking as a risk factor for stroke• Pharmacological therapy should be

documented if prescribed at discharge

• Develop standardized patient education materials to be used for inpatients and at discharge

• Inpatient materials could include written information or recorded (DVD or closed circuit television)

• Discharge materials could include written information

• NursesPrimary Staff Affected/Involved

Patient Stroke Education Strategies for Implementation

ResourcesStroke Clinical Tools Library, AHA http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelinesHFStroke/GetWithThe-GuidelinesStrokeHomePage/Stroke-Clinical-Tools-Library_UCM_303743_Article.jsp

stK 9 Continued - Page 34

Documentation Process Strategies for Implementation

Iowa Stroke Performance Improvement Toolkit

Discharge Order Set Strategies for Implementation

Develop standardized discharge order set that includes information about tobacco use. • Include a mechanism for follow-up after discharge.

• Develop process for hospital staff to follow-up after discharge

• Refer to a quit line for follow-up after discharge• Give available cessation program resources

• Develop a protocol for pharmacological therapy• Patient has medication at discharge• Patient has prescription for medication

• NursesPrimary Staff Affected/Involved

Incorporate a question about tobacco use on the stroke admission order set and into the nursing history and physical form• Tobacco use could be incorporated into the vital signs

section of the admission order set • Questions could include:

• Tobacco use status• Willingness to attempt to quit while in the hospital• If not willing, are they interested in withdrawal relief

while hospitalized?

Develop standing orders for smoking cessation to begenerated for all positive responses that includes bedside consultation and pharmacological therapy options. • Development of a standing order form could be a

hospital-wide initiative to assure consistency inpatient care across all units

• Physicians • Nurses

Primary Staff Affected/Involved

stK 9 Continued - Page 35

Iowa Stroke Performance Improvement Toolkit

sTK - 10 assesseD for reHabiliTaTion

Admission Order Set Strategies for Implementation

Develop a standardized admission order set that includes therapy consultations• Include PT, OT, and SLP

Develop a documentation process to include therapy consultations• Information on therapy consultations

can be included in the EHR• If paper charting, the consultations

should be documented in the patient’s chart

• Physicians• Nurses• PT• OT• SLP

Primary Staff Affected/Involved

Discharge Order Set Strategies for Implementation

Develop a standardized discharge order set that includes therapy consultation • Include PT, OT, and SLP• The discharge order set should include

documentation that the patient was assessed for rehabilitation

• Include a place to document if the patient was ineligible for rehabilitation and the reason(s) why.

Develop a protocol for rehabilitation services • Include documentation about the

referral: agency name, location, contact information

• Schedule the first appointment for the patient and include this information on the discharge orders

Include a mechanism for follow-up after discharge• Develop a process for hospital staff to

follow-up with the patient or caregiver after discharge to address any barriers to attending rehabilitation.

• Physicians• Nurses

Primary Staff Affected/Involved

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Resources - Admission and DischargeOrder set examples, AHA: http://www.heart.org/HEARTORG/HealthcareRe-search/GetWithTheGuidelinesHFStroke/GetWithTheGuidelinesStrokeHomeP-age/Stroke-Clinical-Tools-Library_UCM_303743_Article.jsp

noTes:

Questions or Comments For questions or comments about the Performance Improvement Toolkit, please contact Ellyn Cowan at [email protected]