journey to acute stroke ready certification

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JOURNEY TO ACUTE STROKE READY

CERTIFICATION

Bernie Oberrecht RN MSN NE-BCDirector of Critical Care for St. Elizabeth HealthcareSystem Stroke Program Coordinator • Currently @ St. Elizabeth Healthcare

– Edgewood – PSC – Florence – PSC

Fort Thomas PSC– Fort Thomas – PSC

• Currently – 2 ASRH facilities– Covington (free standing Emergency Dept.) – ASRH– Grant County (CAH) – ASRH

E-mail [email protected] – (859) 301-9449

DISEASE SPECIFIC CERTIFICATIONAcute Stroke Ready Hospital

OBJECTIVES:• Assess Eligibility Criteria• Review Hospital requirements for certification

• Preparing for ASRH certifications – disease specific processes• Preparing for ASRH certifications – disease specific processes – meeting Joint Commission requirements

• Selecting Clinical Performance measures

• Prepare for survey• Follow the Joint Commission’s agenda for survey• Best to utilize the Joint Commission’s outline of requirements in

the Joint Commission Manual for Disease Specific Care• Preparing an Opening presentation • Organizing a Data presentation• Provide a binder of documents for the surveyor’s review

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Acute Stroke-Ready HospitalWho should consider ASRH certification? Designed as a certification for off-site or free standing Emergency

Departments within a Stroke System of Care. Al f C iti l A H it l Also for Critical Access Hospitals

• A recommendation from the “Brain Attack Coalition”

The Benefits…………..• Encourages a collaborative relationship with local EMS• Provides a consistent approach to assessments and treatment protocols• Offers opportunities for an organized process improvement model• Allows off-site facilities to be recognized for quality stroke care delivered

in remote facilities.

• Preparing for ASRH certification– 1st assure all Hospital Requirements are met

• The identified Acute Stroke Ready facility is owned andThe identified Acute Stroke Ready facility is owned and operated by a Medicare participating hospital as a provider based emergency department.

• This (proposed ASRH) facility shares the same Medicare / Medicaid (CMS) certification number as the main hospital.

• The (proposed ASRH) facility was been surveyed as part of the Joint Commission Triennial accreditation survey.

• Preparing for ASRH certification– Additional Hospital Requirements

• The medical staff and nursing personnel of the off-site facility, must be a part of the participating Hospital as a y, p p p g psingle organization.

• The Medical Director of the Stroke Program is on staff at the main hospital.

• There is a single Medical record system• The off-site facility’s emergency department meets all

EMTALA requirements.• The facility considering ASRH certification Must

serve at least 10 stroke patients annually.

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• Preparing for ASRH certification– ASRH Facility must meet all Joint Commission

requirements for certification• Must have access to protocols used by EMS• The Acute Stroke Team must be available 24/7 – to be at theThe Acute Stroke Team must be available 24/7 to be at the

bedside within 15 minutes• CT – MRI – and Lab is available 24/7 in the facility• Neurologist accessible is 24/7 in person or Tele-medicine

– Tele-medicine must be available within 20 min of the request.• Neuro-surgical services – available within 3 hours • The ability to provide IV thrombolytic – t-PA• Transfer protocols in place• Next step …………………………………

• Before completing the application for ASRH certification………….– Create your own checklist

• Be sure that all Hospital requirements have been met• And that your facility is compliant with all primary Joint

Commission requirements.– Be prepared to demonstrate compliance with identified

CPG – (Clinical Practice Guidelines)• The ASRH facility will follow the same guidelines as the main

facility or PSC / CSC– Identify a minimum of 4 performance measures – at least

2 related to clinical practice

• Performance Measures– ASRH – must comply with Stage 1 requirements for

Performance Measurement– Must collect and analyze data on at least 4 performance

measures related to or identified in (CPG) or is ( )recommended in CPGs

– The focus is on the use of performance measures for improving care

– Demonstrate the use of the “cycle” for improvement– Implement a plan for improvement use of graphs– Evaluate the effectiveness of your plan

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• Performance Measures– ASRH – Stage 1 requirements for Performance

Measurement– 2 of the 4 measures – Must be Clinical– Other measures can be

• Perception / Patient Satisfaction• Functional• Financial

– Must collect data on the 4 measures prior to submitting your application.

• Submit your application• With the initial survey – you will receive 30 days

notice prior to your survey date.• Reminder: “BE READY” when the application is• Reminder: - “BE READY” when the application is

submitted.– Must have at least 4 months a data and be able to

demonstrate compliance • For re-certification -( in 2 years)

• 7 business days notice will be provided prior to survey• Must have 12 months of data

• The day of survey• Joint Commission agenda• Begin with the Opening Presentation

Disease Specific Care Initial Certification April 19-20, 2016

Day 1 (Covington)8:00 - 9:00 a.m. Covington Conference Room

Opening Conference and Orientation to Program

9:00 - 9:30 am Reviewer Planning Session

9:30 am - 12:30 Individual Tracer Activity

• Data (Quality) presentation• Competency assessment• Opportunity for issue resolution• Closing

9:30 am - 12:30 pm

Individual Tracer Activity

12:30 - 1:00 pm Reviewer Lunch1:00- 4:00 p.m. Individual Tracer Activity4:00 - 4:30 p.m. Reviewer Planning SessionDay 2 (Grant)8:00 - 11:00 a.m. Individual Tracer Activity11:00 a.m. -12:00 p.m. Grant Conference Room

System Tracer- Data Use

12:00 - 12:30 p.m.

Reviewer Lunch

12:30 - 1:30 p.m. Grant Conference Room

Data Presentation

1:30 - 3:00 p.m. Competence Assessment/Credentialing Process3:00 - 4:00 p.m. Issue Resolution and Reviewer Report Preparation4:00 - 4:30 p.m. Grant Conference Room

Program Exit Conference

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OPENING PRESENTATION


• Showcase your facility/ organization• Provide answers to questions you know they will

ask – such as ……..– Have you met the Eligibility criteria– And Certification requirements - / Joint Commission

Acute Stroke Ready HospitalCertification

2016 – Covington / Grant County

WELCOME TO WELCOME TO NORTHERN KENTUCKY NORTHERN KENTUCKY

ANDAND

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496172

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Primary Service AreasCOVINGTONCOVINGTON

GRANT COUNTY

St. ELIZABETH COVINGTON Facility

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Covington Facility

•• FreeFree--standing Emergency Departmentstanding Emergency Department– Originated on 20th Street –

as a part of the North facility

– For more than 150 years, St. Elizabeth Healthcare has been the heart and soul of the Northern Kentucky Community

Current Facility• 1500 James Simpson Jr. Way since 2009

•• 18 18 bed Emergency facility bed Emergency facility (includes 2 trauma rooms)With access to Radiology –CT MRI Lab 24/7CT – MRI – Lab 24/7

• The facility averages 35,000 ED visits/yr.

•• In In 2015 received 5501 Squads 2015 received 5501 Squads from multiple FDsfrom multiple FDsMajority from CovingtonAlso Newport – Ft. Wright – Ludlow – Cincinnati

St. ELIZABETH

GRANT COUNTY Facility

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Grant County

• Grant County – original site built in 1964 as a CAH

The current Emergency Department

– 8 ED beds – one as trauma with a Tele-ICU monitor

– In 2015 – 19,117 ED visits– 1,614 resulted in admission to

EDG – FLO – FTT - 8.5%– Hours of operation – 24/7built in 1964 as a CAH

– Purchased by St. Elizabeth in 1994

– with physician specialty services added in 2003

– New (current) Building built in 201 0

• The facility also has a MMU(Medical Monitored Unit)

• Physician Specialty Services –Mon - Fri– RT – EKG – Lab – CT – MRI

services available

Stroke ProgramSt. Elizabeth Healthcare recognizes the importance of of Stroke Care.

• St. Elizabeth Edgewood – achieved Advanced Primary Stroke Certification Advanced Primary Stroke Certification in 2008 – 2010 – 2012 – 2014in 2008 2010 2012 2014

• St. Elizabeth Florence and Fort Thomas –achieved Advanced Primary Stroke CertificationAdvanced Primary Stroke Certificationin 2006 – 2008 – 2010 – 2012 – 2014

• The Covington and Grant County facilities are a part of the St. Elizabeth Healthcare Stroke Program and request to be recognized as ASRHASRH

Stroke Program LeadershipStroke Program Leadership• St. Elizabeth Administration supports the Stroke

Program– Through participation in Stroke Quality Committee

and Stroke Steering Committees– Development and implementation of “Stroke Specific” p p p

job descriptions and policy and procedures.– Integration of the program into the organizational

Strategic Plan• Communication Plan of Quality outcomes

– Stroke Quality to Stroke Steering committee– To Quality Improvement Committee– The Board of Trustees

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Mission and VisionOur Mission

As a Catholic healthcare ministry, we provide comprehensive and compassionate care that improves the health of the people we serve.

Our Vision

St. Elizabeth is the preferred destination for healthcare, where innovative

professionals deliver the highest quality of care.

The Stroke Program provides :• comprehensive primary

prevention through community education and screening,

• delivery of acute care services in adherence with treatment standards,

• post-acute education and support in collaboration with our community partners.

The stroke program model of care • will promote wellness, • provide care, and • ensure support for all people

whose lives are affected by stroke.

Membership:• Accreditation Services

Stroke Steering CommitteePurpose:

• Provide administrative and clinical oversight

• Strategic Planning

•Meets Quarterly

• Program Medical Director

• Quality Director Radiology

• VP Nursing / Site CNO

• System Program Stroke Coordinator

• ED Director / Stroke Coordinator

• Director Therapy Services

• Director Radiology

• Accreditation Services

• Quality Management

• Care Coordination

• Stroke Unit Coordinators

(Facility representative)

• Quality manager Lab

• Accreditation spec. - Radiology

Stroke Quality Committee• Committee meets monthly• Review ……..

– Updates of Accreditation standards – Any core measure fallouts– tPA Door to Needle results

Turnaround times for– Turnaround times for • Labs – CT – EKG

• Recommend revision to– Stroke protocols– CPG updates

• Provide education– On stroke measures

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Team Composition

Roles and Responsibilities

• Job Descriptions– Medical DirectorDr. James Farrell

– System Stroke Program Coordinator

– Stroke Unit Coordinators– Chris Schewe RN ANM

Covington ED– Liberty Delisle RN ANM

Grant County ED

Bernie Oberrecht RN MSN

– System ED Stroke Coordinator

Betsy Jackson RN MSN

– System Stroke Emergency Services Educator

Betty McGee RN BSN

Stroke Program Scope of Service

• Target population:

Ischemic, Hemorrhagic, (ICH) and TIA patients.

•Acute Stroke Ready:

• At the Covington facility (free standing Emergency Dept.)

and the Grant County facility (a CAH)

the team is READY to facilitate care.

• When signs and symptoms of stroke are identified –a Code Stroke Alert is called – which includes notification of the UC Stroke Team.

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Stroke Patient Population2015 Demographics

GRANT COUNTY

ISCHEMIC HEMORRHAGIC TIATOTAL PATIENTS 26 6 1AVERAGE AGE 60.1 63.5 71MALE/FEMALE 18 male /8 female 1 male / 5 female 1 female

LANGUAGE 100% English 100% English 100% EnglishEHNICITY 100% Caucasian 100% Caucasian 100% Caucasian

COVINGTON

ISCHEMIC HEMORRHAGIC TIATOTAL PATIENTS 35 3 0AVERAGE AGE 64.8 77.3Male/female 18 male /17 female 3 male / 0 femaleLANGUAGE English 100% English 100%

ETHNICITY33 Caucasian – 82%

7 black – 18%2 Caucasian – 67%

1 black – 33%

Covington GrantAll Strokes

AcuteLSN < 3 hrs

tPa All Strokes

AcuteLSN < 3 hrs

tPa

2 0 0 4 1 0

3 0 0 3 0 0

1 1 0 2 1 0

2 1 1 1 0 0

0 0 0 1 0 0

6 1 0 2 1 1

COVINGTON• In 2015, 37 patients were treated in

the Covington Emergency Dept. and admitted to a St. Elizabeth facility, with a discharge diagnosis of acute / chronic ischemic stroke, TIA or Hemorrhagic stroke.

• 9 patients arrived with 3 hours of LSN – eligible for treatment.

• 2 patients treated with tPA

6 3 0 3 2 0

3 1 0 1 0 0

4 1 1 2 0 0

4 1 0 1 1 0

3 0 0 3 0 0

3 0 0 4 1 0

37 9 2 27 7 1

GRANT• In 2015, 27 patients were treated in

the Grant County Emergency Dept. and admitted to a St. Elizabeth facility, with a discharge diagnosis of acute / chronic ischemic stroke, TIA or Hemorrhagic stroke.

• 7 patients arrived with 3 hours of LSN – met eligibility criteria.

• 1 patient was treated with tPATotal

UC Stroke Team Model• 16 local hospitals (5 PSCs)

– EMS brings pts to nearesthospital

– UC Stroke team MD drives to all local hospitals

– Encourage pre-notification (prior to CT completion)to CT completion)

– Study coordinator comes if possible trial candidate

• Additional ~15 regional hospitals– Drip & ship by phone assessment

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Greater Cincinnati/Northern Kentucky Stroke Network

•Multi-Disciplinary Team– 7 Emergency Physicians

– 8 Neurologists

– 7 Vascular Neurologists

– 3 Neuro-interventionalists

– 11 Acute Research Coordinators11 Acute Research Coordinators

– 6 fellows

•16 Hospitals– 1 University

– 3 Teaching

– 12 Community•9 regional hospitals utilizing Telemedicine

2.1 million population for metropolitan area;About 30 miles between farthest hospitals;

Crosses state lines

The EMSEMS Connection• Pre-notification

– Call ahead – allows the Emergency Dept. to be prepared and immediately move into action.

• Stroke Treatment protocols are initiated in the fieldStroke Patient destination protocols are in place andutilized by EMS

EMS Protocols• Kentucky state EMS protocols have been adopted and

are followed by both Covington Fire Department and Dry Ridge Fire Department.

• These two departments are responsible for the transporting the most patients to our Covington and Grant facilitiesGrant facilities.

• The Kentucky state EMS protocols were last updated in September of 2015.

• The Cincinnati Pre-hospital Stroke Scale is the assessment tool that is used by EMS personnel in Kentucky.

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EMS training and Education

• Twice a year, stroke topics are covered by our EMS Monthly Lecture Series. These lectures are attended both in person and via GoToTraining on the web. These are saved so that they can be accessed throughout the year for refresher training if needed.

• Dr. Ty Brown, neurologist, will be speaking on CVA and a-fib, during the month of June, 2016

• Emily Goodall, educator from the UC Stroke Team, will be presenting in November 2016, on use of the pre-hospital assessment tool and what the stroke team needs to know from EMS prior to their arrival.

Hospital PoliciesHospital Policies• Policies available regarding:

– Assessment– Criteria for admission –– transfer – discharge

of stroke patientsof stroke patients

– Transfer Protocol• To a St. Elizabeth Primary Stroke Center• To University Hospital for endovascular procedure• To other facilities with an accepting physician at

the patient’s or physician’s request.

Transfer protocols

• Protocols are in place for the timely transfer of all stroke patients to a Primary Stroke Center

• Ground transportation per –l / S 24/Rural Metro / PTS 24/7

• Air options – Air Evac & University of Cincinnati

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Physician consultationPhysician consultationACCESS TO STROKE EXPERTISE

• St. Elizabeth Neuro Surgery consult –on-call 24/7 – paged via Perfect Serve

• St. Elizabeth Neurology consult –on-call 24/7 – paged via Perfect Serve

UC Stroke Team available • for all patients LSN 12 hours or less

– The UC Stroke Team will be notified– Patients receiving TPA will be followed by the UC stroke

Team for 24 hours

Care – Treatment – and Services provided

• All Staff are educated on CPGand follow defined parameters on stroke care

• Physician Order sets – emergency Dept.•• ED Stroke ProtocolED Stroke ProtocolED Stroke ProtocolED Stroke Protocol•• tPAtPA protocolprotocol•• TeleTele--StrokeStroke – is available for

immediate assessment by a neuro specialized physician

Stroke ChecklistStroke Checklist

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CPG• Table 5. ED-Based Care• Action Time• Door to physician ≤10 minutes• Door to stroke team ≤15 minutes• Door to CT initiation ≤25 minutes• Door to CT interpretation ≤45 minutes• Door to drug (≥80% compliance) ≤60 minutes• Door to stroke unit admission ≤3 hours

Guidelines for Early Management of Patients with Acute Ischemic Stroke: 2013 Jauch, et al.

A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

Clinical Practice Guidelines• Guidelines for Early Management of Patients with Acute Ischemic

Stroke: 2013 Jauch, et al. A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

• Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults - 2010, Morgenstern, et al. American Stroke Association.

• Guidelines for prevention of Stroke in Patients with Stroke or Transient• Guidelines for prevention of Stroke in Patients with Stroke or Transient Ischemic Attack 2011 Furie, et al. American Stroke Association

• Recommendation for the Establishment of Primary Stroke Centers – 2011, Alberts et al. American Heart Association.

• Expansion of the Time Window for Treatment of Acute Ischemic Stroke with Intravenous Tissue Plasminogen Activator- 2009, Zoppo, et al. American Heart Association

Education of staffAll Nursing staff assigned to areas where our stroke population may be cared for ………………..Will receive the following education:• CPG – with orientation

and annuallyand annually• NIHSS – with orientation –

re certification every 2 yrs. • BSS evaluation – with orientation

and annually• Administration of tPA

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t-PA (Alteplase)

Staff are educated on the following:• Preparation of the drug – prior to

administration• Understanding the purpose of thrombolytic g p p y

therapy• Inclusion / exclusion criteria for t-PA• t-PA protocol – standard of care

• Frequency of vital signs• Monitoring the patient for adverse reactions

Additional education• Annual stroke education on the Care of the

Stroke Patient• All new hires with orientation• Annually – in MID

• Neuro Symposium – available annually –• Neuro Symposium – available annually –sponsored by St. Elizabeth Staff Development

• Stroke Symposium – annually sponsored by the GCSC– Greater Cincinnati Stroke Consortium

• Opportunities for Webinars – made available to the Stroke Quality Committee

Therapy Service• Physical Therapy

• All patients are evaluated for the need for PT / OT

• Speech Therapy• All patients are screened for dysphagia – prior

to receiving any food, fluid or medication.to receiving any food, fluid or medication.• Speech Therapy is consulted any time there is a

failed Bedside Swallow evaluation.

• Rehabilitation • Services are initiated indicated by the patient

assessment.

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Discharge Support• Care Coordination staff/ Social workers are

available – To assist patients with arrangements for care after

discharge– Out patient physical therapy or speech therapy

availabilityavailability

• Referrals to Hospice or palliative care are available as needed through the Healthcare system

• It is our Goal to discharge to a Primary Stroke center within 2 – 3 hours

Community Support Group

Northern Kentucky Regional Stroke Northern Kentucky Regional Stroke Support GroupSupport Group

• A joint association between St Eli b th h lth– St. Elizabeth healthcare

– Gateway Rehabilitation Hospital

– HealthSouth Rehabilitation Hospital

The group originated in 2011

Community Support GroupCommunity Support Group

Purpose –to provide an open forum for care givers and stroke victims to discuss issues , problems that may be challenging to them.

– Re-organization in 2015 – revised in 2016Re organization in 2015 revised in 2016 • Monthly event at each facility

– Topics chosen from group request

– Collaboration with area rehab centers

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Cardiovascular Mobile Health Van

Partners in community education:

CV Screenings including Stroke Education

Identifying Stroke Risk factors

• Education distributed by the Mobile Van• Community events

– Strike Out Stroke

Ed ti il bl t id t th ti t• Education available to provide to the patient and to the family in the Emergency Dept.– patient specific Risk factors for stroke discussed

upon discharge

• Community resources available as needed

THANK YOUTHANK YOU

WELCOME TO WELCOME TO ST ELIZABETHST ELIZABETHST. ELIZABETHST. ELIZABETH

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DATA PRESENTATIONQuality Improvement initiatives

• Discussion of quality measures chosen


q yfor your facility

• Show a minimum of 4 months data collection• The importance of the measures identified• How will greater compliance of each measure

provide improvement to your stroke program

Acute Stroke Ready HospitalQUALITY PRESENTATION

2016 – Covington / Grant County

Stroke Program Performance Improvement

The performance improvement plan for the Stroke Program is integrated with the organizational performance improvement plan.

The objective of the plan is to

• monitor identified areas of opportunity across

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pp ythe system,

• develop action plans,

• evaluate the results of the action

• and then continue to monitor for performance stability or improvement.

When implementing a PI project the departments and/or team follows the PDSA (plan, do, study, act) cycle.

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Stroke Program PIFlow of Information

Quality Improvement Committee

Board of Trustees Stroke Steering Committee:

• Provide administrative and clinical oversight

• Strategic Planning

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Individual Departments

Stroke Quality Committee

Stroke Steering Committee Stroke Quality Committee:

• Review quality data and develop action plans

• Develop evidenced based program content

Performance Improvement

Current Initiatives• Code Stroke Alert

– Go-Live Feb. 1, 2016 for Covington and Grant– GOAL – to improve turn-around-times for labs – CT – EKG

• Tele-Stroke– Originally implemented at Grant County in 2014– Go-Live April 4, 2016 – for Covington– GOAL – to improve Door to Needle

CODE STROKE ALERT

• The Team is alerted using the following criteria:– The patient exhibits sign/symptoms of stroke– LSN is reported as less than 12 hours

• The ED Team consist of the following:– ANM / CN – who will alert the ED Physician

• If going immediately to CT – will do a brief assessment

– ED Tech – responsible for lab draws– CT Tech – pt is on the way (prepare for the patient)– Pharmacy – heads up possible tPA admin– Lab – heads up specimen will be arriving shortly

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Stroke Team Notification

• Initial notification – with the Code Stroke Alert to UC / pager– UC Stroke Team policy – return the call within 5 min– RN – provides a brief history to determine tPA eligibility

• 2nd call – UC stroke Team – Tele-stroke– if tPA eligibility criteria is under consideration– Pt return from CT– Connect Tele-Stroke– Full assessment / NIHSS completed

Tele-Stroke

Decision will be made to administer tPA by UC Stroke Team MD –

Stroke Team MD -will then come to the St. Elizabeth facility to further assess and evaluate the patient.

Data CollectionData Collection

CURRENT PRACTICE• We collect Data on monthly basis

• We monitor the data for documentation compliance

OPPORTUNITY

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• To evaluate what we are monitoring

• Determine where the problem area exist

• Develop a new Action Plan

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Covington GrantAll Strokes Acute

<3 hrs.tPa All Strokes Acute

< 3 Hrs.tPa

2 0 0 4 1 0

3 0 0 3 0 0

1 1 0 2 1 0

2 1 1 1 0 0

0 0 0 1 0 0

6 1 0 2 1 1

COVINGTON• In 2015, 37 patients were seen in

the Covington Emergency Dept. and admitted to a St. Elizabeth facility, with a discharge diagnosis of acute / chronic ischemic stroke, TIA or Hemorrhagic stroke.

• 9 patients arrived within 3 hours of LSN – met tPA eligibility criteria.

• 2 patients were treated with tPA

GRANT

2015

Month

January

February

March

April

May

June

6 3 0 3 2 0

3 1 0 1 0 0

4 1 1 2 0 0

4 1 0 1 1 0

3 0 0 3 0 0

3 0 0 4 1 0

37 9 2 27 7 1

GRANT• In 2015, 27 patients were seen in

the Grant County Emergency Dept. and admitted to a St. Elizabeth facility, with a discharge diagnosis of acute / chronic ischemic stroke, TIA or Hemorrhagic stroke.

• 7 patients arrived within 3 hours of LSN – to meet t-PA eligibility criteria

• 1 patient was treated with tPA

July

Aug

September

October

November

December

Total

Not Treated – Reasons (2015)

Reason COVINGTON GRANTTime LSN >180 minutes 26 Pts. – 70% 16 Pts – 60%

Minimal deficit or rapidly improving

3 Pts. – 8% 6 Pts – 22%

CT ICH/SAH 2 Pts. – 6% 4 Pts – 15%

SeizureSeizure

Too severe neurological deficit

Patient/family refused

Recent previous stroke

Not Diagnosed as a stroke while in the ED

4 Pts. – 10%

Other

Total 35 Pts not treated 26 Pts not treated

Covington GrantAll Strokes Acute tPa All Strokes Acute tPa

3 1 1 2 1 0

4 2 0 4 0 0

1 0 0 3 0 0

COVINGTON• In 2016 in the 1st 2 months of the year, there

were 7 patients treated in the Covington Emergency Dept. and admitted to a St. Elizabeth facility, with a discharge diagnosis of acute / chronic ischemic stroke, TIA or Hemorrhagic stroke.

• 3 patients arrived within 3 hours of LSN

• 1 patient was treated with tPA

• Patients not treated –Stroke team notified -symptoms improved

GRANT

2016

Month

January

February

March

April

May

• In 2016 in the 1st 2 months of the year, 6 patients were treated in the Grant County Emergency Dept. and admitted to a St. Elizabeth facility, with a discharge diagnosis of acute / chronic ischemic stroke, TIA or Hemorrhagic stroke.

• 1 patient arrived within 3 hours of LSN • was not treated with tPA – Stroke team

notified - further clarification of LSN

June

July

Aug

September

October

November

December

Total

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SelectedPerformance Measures1. MD will assess the patient within 15 min (Arrival to Bedside)

2. The CT scan will be resulted within 45 min of receiving the order. (Order to results in 45 min)

3. The NIHSS will be completed on all patients who exhibit stroke signs and3. The NIHSS will be completed on all patients who exhibit stroke signs and symptoms

4. A Bedside Swallow Dysphagia screen will be conducted on all potential stroke patients prior to the patient receiving and PO food, fluids, or oral medications

Determined as best practice – CPG – Guidelines for Early Management of Patients with Acute Ischemic Stroke: 2013 Jauch, et al. And Disease Specific care (ASRH

CPG• Table 5. ED-Based Care• Action Time• Door to physician ≤10 minutes• Door to stroke team ≤15 minutes• Door to CT initiation ≤25 minutes• Door to CT interpretation ≤45 minutes• Door to drug (≥80% compliance) ≤60 minutes• Door to stroke unit admission ≤3 hours

Guidelines for Early Management of Patients with Acute Ischemic Stroke: 2013 Jauch, et al.

A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

QUALITY MEASURES 2015

Covington ED 2015 Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec

Ischemic 2 3 1 2 0 6 6 3 2 5 4 1

Hemorrhagic 0 0 0 0 0 0 0 0 0 1 0 2

Turn Around Times for All Stroke Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

ED Measure Goal

% Pts. MD to bedside < 15 mins

SE >75% 50% 67% 100% 100% na 83% 83% 100% 100% 67% 100% 100%< 15 mins.

% Pts. CT – Order to results total time < 45 mins

JC >75% 100% 100% 0% 100% na 100% 67% 100% 100% 60% 50% 33%

%Pts. Glucose < 15 mins. SE >50% 50% 33% 0% 100% na 67% 0% 33% 100% 67% 33% 0%

%Pts. Glucose < 45 mins. SE >75% 50% 67% 100% 100% na 83% 50% 33% 100% 75% 100% 67%

% Pts. NIHSS completed SE >75% 100% 100% 100% 100% na 100% 83% 100% 75% 100% 67% 33%

% Pts. BSS eval completed SE >75% 100% 100% 100% 100% na 100% 50% 66% 50% 75% 67% 33%

# of Pts receiving TPA 0 0 0 1 0 0 0 0 1 0 0 0

Door to Needle – Time in Min

50% 151 52

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QUALITY MEASURES 2016Covington ED 2016 Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec

Ischemic 3 4 1

Hemorrhagic 0 0 0


ED Measure Goal

% Pts. MD to bedside < 15 mins.

SE >75% 67% 75% 100%

% Pts. CT – Order to results total time < 45 JC >50% 67% 100% 100%mins

%Pts. Glucose < 15 mins. SE >50% 67% 100% 100%


% Pts. NIHSS completed SE >75% 67% 75% 100%% Pts. BSS evalcompleted

SE >75% 67% 75% 100%

# of Pts receiving TPA 1 0 0

Door to Needle – Time in Minutes

50% 127 min0% na na

Improvement Opportunitiesfor Covington

• Monitor Compliance of Code Stroke Alert– Enter CT order as stroke protocol (to expedite results)– ED Tech to IMMEDIATELY obtain:

• BGL stat (accu-check)• draw stroke labs

• Notify the Stroke Team for all potential stroke patients with a LSN of 12 hours or less

• Re-Educate all RNs on the Standard of Care for any patient exhibiting Signs/Sym of stroke– NIHSS with initial assessment– BSSS – prior to any PO food – fluids – PO meds

• Remember to document the REASONS WHY an assessment requirement can not be completed

QUALITY MEASURES 2015Grant County ED 2015 Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec

Ischemic 4 0 2 1 1 3 2 1 2 1 2 3

Hemorrhagic 1 1 0 0 0 0 1 0 0 0 0 0Turn Around Times for All Stroke Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

ED Measure Goal% Pts. MD to bedside

< 15 mins.SE >75% 75% 100% 100% 100% 100% 100% 67% 100% 100% 100% 67% 100%


JC >75% 100% 100% 100% 100% 100% 100% 100% 0% 0% 100% 0% 100%

%Pts. Glucose < 15 mins. SE >50% 75% 50% 100% 0% 100% 0% 100% 100% 50% 100% 33% 75%

%Pts. Glucose < 45 mins. SE >75% 75% 67% 100% 100% 100% 0% 100% 100% 100% 100% 67% 100%

% Pts. NIHSS completed SE >75% 67% 100% 67% 100% 100% 100% 100% 100% 100% 100% 100% 100%

% Pts. BSS eval completed SE >75% 50% 100% 67% 100% 100% 100% 100% 100% 50% 100% 100% 100%

# of Pts receiving TPA 0 0 0 0 0 1 0 0 0 0 0 0

Door – To – Needle time 50% 100 min

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QUALITY MEASURES 2016Grant County ED 2016 Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec

Ischemic 2 4 3Hemorrhagic 0 0 0


ED Measure Goal

% Pts. MD to bedside SE >75% 100%

10067%< 15 mins.

SE >75% 100%%

67%


JC >75% 100%100%

100%


%Pts. Glucose < 45 mins. SE >75% 100%100%

100%

% Pts. NIHSS completed SE >75% 100% 75% 100%% Pts. BSS eval completed SE >75% 100% 75% 100%# of Pts receiving TPA 0 0 0

Door – To – Needle time 50% na na na

Improvement OpportunitiesGrant County

• Monitor Compliance of Code Stroke Alert –early recognition of possible Stroke– ED Tech to IMMEDIATELY obtain:

• BGL stat (accu-check)• draw stroke labs

• Notify the Stroke Team for all potential stroke patients with a LSN of 12 hours or less

• Re-Education of all RNs on the Std. of Care– Focus on getting the patient to the CT scan sooner– NIHSS with initial assessment– BSSS – prior to any PO food – fluids – PO meds

Program GOALSProgram GOALS

1. Staff and Community Education

STAFF• Neuro Symposium – an

Annual Spring Event– Sponsored by St.

Elizabeth Healthcare

COMMUNITY• Community educational events

throughout the year• METS Center• Strike-Out Stroke

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• Stroke Symposium – a fall event– Sponsored by the

GCSC• May as stroke Month

– A focus on education on all stroke units

– Review CPG (Clinical Practice Guidelines)

• May 11, 2016 @ the Ball Park• Sponsored by the GCSC

• May as stroke month• Stroke prevention info

distributed• Emergency Dept. waiting

areas• Cafeteria

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2. Performance Improvement The GOLDEN HOUR –

continue to improve Door to Needle times

Perfection of Code Stroke Alert To identify stroke S/S sooner – improve patient outcomes

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Use of Tele-Stroke – to improve Drug Administration times

Monitor the Standard of Practice Documentation compliance

3. Regulatory Compliance To meet all ASRH standards


4. Community Partnership UC Stroke Team Northern Ky. – EMS SEQIP (Stroke Encounter Quality Improvement

Project)

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GCSC (Greater Cincinnati Stroke Consortium)

5. Physician Engagement MD Involvement in order set development MD participation in all stroke initiatives Current Member of the Stroke Quality Committee

PERCEPTION OF CARE

• Patients are currently surveyed with regard to their satisfaction on treatment and services provided.

• Results are summarized by their Discharged facility• Comments by patients or family members (regarding care and

i ) id d f f llservices) are provided for managers to follow up as appropriate.

• There are opportunities to re-design how patient/family feedback is used to improve the program and better meet patient needs.

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Opportunities for ImprovementFeedback from the Surveyor• When analyzing your data – remember to develop an effective

action plan – to alter your data – improve the program

• Opportunities:• Perception of Care

– Data is aggregated at the program level (ASRH) (DSPM3 – A6)• Surveyor is not interested in overall data from Main Hospital

– The Program evaluates Patient Satisfaction with and perception of quality of care at the program level.

– Patient satisfaction data is utilized for program specific performance improvement activities. (DSPM.5)

STROKE BINDER (not a requirement)

• The availability of program documents that will support compliance based on the Joint Commission Manual for Disease Specific Care


Binder• Provide an organized method

– Use the Joint Commission Manual by Standard– Provide documents that support each standard

Documents to include in the Stroke Binder

1. The Agenda for Day• With list of participants

2. Letter of Support from the Hospital administrator3. Stroke specific policies

• Organizational Plan• Ethics – Rights and ResponsibilitiesEthics Rights and Responsibilities• Mission and Vision• Downtime and Diversion policies

4. Stroke Program specific contracts5. Transfer agreements with PSC (if applicable) 6. Core Team composition7. EMS protocols8. Target Population9. Scope of Practice10. Stroke Protocols

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Documents to include in the Stroke BinderContinued……………11. Stroke Job Descriptions – if applicable 12. Formulary / TPA13. CPG – Clinical Practice Guidelines14. Dashboards – Quality Measures15. PDSA – Action Plans16. Staff education Plan

• Orientation – annual – stroke unit specific

17. Physician education18 MD compliance19 Patient Satisfaction data / Perception of Care

• Binder of Stroke Education for members of the Core Team• Binder of Committee Meetings

QUESTIONS