participating in a data-driven qi for stroke … · · 2011-06-30participating in a data-driven...
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PARTICIPATING IN A DATA-DRIVEN
QI FOR STROKE AND TIA
Anna Hogen, Abbot Northwestern Hospital
Deb Nyquist, MD, FAAFP, Grand Itasca Clinic &
Hospital
June 27, 2011
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Rural Hospital Pilot Project
• Minnesota Stroke Registry
• Minnesota Department of Health
• Paul Coverdell National Acute Stroke Registry (CDC)
• Participating Hospitals
• Grand Itasca Clinic & Hospital, Grand Rapids, MN
• River’s Edge Hospital & Clinic, St. Peter, MN
• Clinical Collaborating Hospital
• Abbott Northwestern Hospital – Neurological Emergency Treatment
(NETwork) program
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Purpose
• Improve relevancy of data for rural hospitals
• Assist rural hospitals
• Data collection – more detailed
• Quality improvement
• Define a place in the statewide stroke system for rural
hospitals
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Minnesota Department of Health
• Coordinate project
• Provide data monthly
• “Host” monthly check in calls
• Review data
• Discuss process improvement
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Abbott Northwestern Hospital
• Comprehensive stroke care
• Access to Neurologic Specialists 24/7:
• Neurologists, Neurosurgeons, Interventional NeuroRadiologists
• Stroke treatment options beyond IV tPA: intra-arterial capabilities
• NETwork program-
• Fulltime, experienced stroke care RN
• Provides feedback/support to referring facilities
• Assist with stroke care resources
• Protocol/order set development
• QI/PI support
• Tele-health for stroke
• Participant in MDH stroke care initiatives
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Grand Itasca Hospital: Who are we?
• Integrated hospital & clinic • Merged in 2002
• New facility in Dec of 2005
• 65 beds including our ARU
• 60+ providers -multispecialty
• Rural • Town of 8,000
• Service area of 40,000
• Independent ANDinterdependent
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Stroke care at Grand Itasca Hospital
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Where we began
• Volume of approx 90/year
• CT capability 24/7
• TPA administration for stokes < 3 hours
• Transfer to larger facility:
• Larger strokes
• Hemorrhagic strokes
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Goals
• Softly Defined Strongly Articulated
• Improved care in our ED
• EMS involvement
• Timely use of TPA
• Rapid turn around times for lab/CT
• Improved care of our hospitalized patients
• CDC Stroke guidelines
• Patient and community education
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Patient population
N (%)
38 (51)
15 (20)
5 (7)
15 (20)
TIA with symptoms completely
resolved prior to presentation to
the emergency department
5 (7)
1 (1)
1 (1)
75 (100)
Stroke not otherwise specified/ill-
defined stroke
Total
Transient ischemic attack (TIA)
Missing
Total
Hemorrhagic stroke
Ischemic stroke
Stroke type
No stroke
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Pre-hospital care goals
• Increase arrival by EMS
• Time “Last Know Well”
• Cincinnati Stroke Scale
• Pre-notification by EMS
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EMS arrival
Mode of arrival N (%)
EMS 36 (51)
Private
transportation/taxi/other33 (47)
Transfer from another
hospital0 (0)
Not documented or unable
to determine1 (1)
Total 70 (100)
Total
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We have seen
• A gradual increase of EMS arrived patients
• Why?
• State and National patient education
• Future plans for local community education
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Documenting time of “last known well”
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Improvements by
• EMS education and encouragement
• Hard-wiring the documentation
• Nursing documentation
• Physician order set
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Cincinnati Stroke Scale
Source: American Heart Association slide.
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Consider a “FAST” scale
• FAST
• Face
• Arm drift
• Speech
• Time of last known well
• Effectiveness
• 1/3 signs as a “new event”
• 72% probability of a stroke
• 3 signs present
• 85% probability of a stroke
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Pre-notification by EMS
Actions by EMS personnel.
EMS actionTotal
N (%)
Total arrived by EMS 36
Pre-hospital notification 23 (64)
Documentation
Time last known well 23 (64)
Blood glucose level 15 (42)
Cincinnati Stroke Scale
Score10 (28)
Other neurological
assessment27 (75)
Not documented/unable to
determine14 (39)
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Pre-notification
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EMS and ED communication
• Modeled after our STEMI and TRAUMA care
• ED physician cell phone
• Direct communication from EMS
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Emergency Department
• Door-to-Imaging time
• Door-to-Lab draw/report
• National Institutes of Health Stroke Scale
• Door-to-Needle time
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Door-to-imaging time
• Goals
• Door to Image < 25 minutes
• Door to Read < 45 minutes
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Door-to-imaging and read times
Minutes
Mean 59 minutes 81 minutes
Median 40 minutes 62 minutes
N (%) N (%)
Missing 12 (17) 16 (23)
0-15 minutes 9 (13) 3 (4)
16-25 9 (13) 2 (3)
26-35 9 (13) 4 (6)
36-45 7 (10) 5 (7)
46-55 9 (13) 7 (10)
56-65 4 (6) 10 (14)
66-75 2 (3) 6 (9)
76-85 0 (0) 2 (3)
More than 85 9 (13) 15 (21)
Total 70 (100) 70 (100)
Door-to-
imaging
performed
time
Door-to-
image read
time
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Learnings
• Pre-notification helps!!!
• Need to manually enter time of study
• Developed a “Super Stat” read by teleradiography
• Stroke diagnosis may evolve over time
• Re: is it uro-sepsis or a stroke?
• Identify late presenters from early presenters
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Door-to-lab draw
Door-to-lab
drawn time
Mean
Median†
N (%) N (%) N (%) N (%)
Missing 1 (6) 1 (6) 2 (12) 5 (29)
0-15 minutes 6 (35) 6 (35) 6 (35) 6 (35)
16-25 2 (12) 2 (12) 2 (12) 4 (24)
26-35 4 (24) 4 (24) 4 (24) 1 (6)
36-45 2 (12) 2 (12) 2 (12) (0)
46-55 (0) (0) (0) (0)
56-65 (0) (0) (0) (0)
66-75 (0) (0) (0) (0)
76-85 1 (6) 1 (6) (0) (0)
More than 85 1 (6) 1 (6) 1 (6) 1 (6)
Total 17 (100) 17 (100) 17 (100) 17 (100)
22 minutes 22 minutes 17 minutes 13 minutes
Time from patient arrival to time lab was drawn or EKG was ordered (door-to-lab drawn
time) among patients who arrived within 3.5 hours of time last known well.
Complete
blood count
(CBC)
Electrolyte
panel with
creatinine
INRDoor-to-EKG
ordered
39 minutes 39 minutes 36 minutes 136 minutes
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Door-to-lab turn-around time
Lab turn-
around time
Mean
Median
N (%) N (%) N (%)
Missing (0) (0) 2 (12)
0-15 minutes (0) (0) (0)
16-25 4 (24) 4 (24) 4 (24)
26-35 5 (29) 5 (29) 4 (24)
36-45 1 (6) 1 (6) 1 (6)
46-55 2 (12) 2 (12) 2 (12)
56-65 1 (6) 1 (6) 1 (6)
66-75 (0) (0) (0)
76-85 1 (6) 1 (6) 1 (6)
More than 85 3 (18) 3 (18) 2 (12)
Total 17 (100) 17 (100) 17 (100)
30 minutes 30 minutes 30 minutes
55 minutes 55 minutes 48 minutes
Arrived within 3.5 hours from time LKW
Complete
blood count
(CBC)
Electrolyte
panel with
creatinine
INR
Time lab was drawn to time lab result was received (lab turn-around
time) among patients who arrived within 3.5 hours of time last
known well.
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Learnings
• We can rarely get an INR < 1 hour
• Purchased point-of-care device
• Pre-notification helps!!!
• Patient diagnosis identification is key
• New lab process to expedite lab results
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NIHSS documented
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Improvements
• New ED Stroke Order Set
• Previously only an in-pt order set
• NIHSS hard-wired into the ED Order Set
• Education of ED docs
• Understanding of the “predictability” of NIHSS
• Helps to talk with patients and families
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Door-to-needle time
• STK-4. Thrombolytic therapy administration.
Percentage of 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.
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Reasons for not giving thrombolytics
Reason N
Contraindications 5
Rapid improvement 4
Mild stroke 2
CT findings 2
Advanced age 1
Warnings 0
Refusal 0
Unable to determine eligibility 0
CMO/illnesses 0
Delay in arrival 0
Others including outside tPA 0
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Thrombolytics
• Every minute counts
• Development of a “Stroke Code”
• Telehealth Initiative with ANW neurologists
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Inpatient care
• Quality Improvement
• CDC Stroke Performance Measure set
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CDC Stroke Measures
NTotal
eligible(%)
STK-1VTE prophylaxis administered by
hospital day two21 24 (88)
STK-2 Discharged on antithrombotic therapy 18 19 (95)
STK-3Discharged on anticoagulant for atrial
fibrillation2 4 (50)
STK-4* Thrombolytic therapy administered* 0 3 (0)
STK-5 Early antithrombotic therapy 14 17 (82)
STK-6 Discharged on statin therapy 4 5 (80)
STK-7 Dysphagia screening 19 30 (63)
STK-8 Stroke education 2 8 (25)
STK-9 Smoking cessation counseling 4 6 (67)
STK-10 Assessed for rehabilitation 25 25 (100)
CDC Stroke Performance Measures for treatment/care of patients with
stroke who were admitted to the hospital.
CDC Stroke Performance Measure set
*STK-4 only applies to patients who arrived at the hospital within two hours
(120 minutes) of time last known well.
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STK–1: VTE Prophylaxis
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STK–2: Discharged on Antithrombotic
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STK–3: A-fib Discharged on Anticoagulant
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STK–5: Antithrombotic Therapy by Day 2
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STK–6 (LDL): Appropriate LDL Reducer
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STK–7: Dysphagia Screening
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STK–8: Educational Materials
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STK–9: Smoking Cessation
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STK–10: Assessed for Rehabilitation
Services
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What have we learned?
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Grand Itasca Hospital
• Pre-notification
• Greases the skids
• Data drives decisions and process improvement
• Hardwiring
• Order-sets
• Standardized areas of documentation
• Difficult with a “paper” system
• Education and communication – KEY
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Barriers
• Our staff wears many hats
• Enlisted our RNs for data collection
• Hiring of a clinical coordinator for Stroke, Trauma, STEMI care
• Data does drive decisions and process improvement
• Hard to obtain in a small hospital on a paper system
• Improvements
• EHR
• Continued participation in the Stroke Registry
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Minnesota Department of Health
• Learnings
• Acute care data
• Novel method of data abstraction
• Facilitated networking – rural hospitals and Primary Stroke Center
• What we’ve done
• Added optional acute care data elements
• Reports on MSRT (scheduled for July)
• National attention
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Questions?