2/20/2017

1

Population Health Management: CNS’s embrace the opportunity to

manage the unique challenges of

disease-specific populations

Nadirah Burgess RN, MSN, ONC

Susan M. Gaunt, MS, APRN, ACNS-BC, ANVP, CCRN, CNRN

Pam Garrett MN, APRN, ACNS-BC, CCRN, CMSRN

Gwinnett Medical Center • 464 - inpatient beds

• 2 acute care medical centers

– Level II Trauma Center

• Acute rehab

• Skilled nursing facility

• Outpatient surgical centers

• Urgent Care facilities

• 5,000+ associates

• 870 affiliated physicians

• Over 29,000 inpatient

admissions and 378,000

outpatient and ED visits

annually

Our Community:

Gwinnett County

• Approximately 30 miles

northeast of Atlanta

• One of the fastest growing

counties in the US for the

past 20 years

• Population 896,000

– 437 square miles

• Ranks 1st in diversity in

GA

https://www.gwinnettcounty.com/portal/gwinnett/AboutGwinnett

https://www.nytimes.com/interactive/projects/immigration/enrollment/georgia/gwinnett

2/20/2017

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Recognition and Awards

• Full Accreditation (all campuses) by The Joint Commission

• Georgia’s Top Large Hospital by Georgia Trend magazine

• America’s Best Hospitals for Obstetrics by Women’s Choice Award

• Platinum Performance Achievement Award by the American College of

Cardiology NCDR Action Registry – GWTG

• Stroke Award Gold Plus, Target: Stroke Honor Roll by the American

Stroke Association

• Mission: Lifeline – Gold Plus Award Quality Achievement Award by the

American Heart Association

• Beacon Award in Critical Care Excellence, both hospitals by the

American Association of Critical Care Nurses

• Heart Failure Silver Award by American Heart Association GWTG

http://www.gwinnettmedicalcenter.org/about-us/awards-and-accreditations

The CNS at GMC

• The first CNS was hired in 1986 shortly after opening the new hospital in Lawrenceville

• Within a few years, our CNS ranks grew and covered service lines and specialty areas – Critical Care

– Med-Surg

– Emergency Services

– Oncology

– Peripartum

– NICU

CNS Role Transitions: 1997-2017

Trauma Registry Coordinator

Outcomes Coordinators

CNS Stroke Program Coordinator

Heart Failure Program Coordinator

Pulmonary Program Coordinator

Total Joint Program Coordinator

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What is Population Health Management?

• GMC population health management is disease / procedure focused:

– Ensure best practices

– Achieve Quality Core Measures

– Coordinate care

– Provide for transition management

CNS as Population Health Coordinators

• The CNS skill set is perfect for population health management

– Focus on quality care and outcomes

– Expertise educating patients, families, and all members of the healthcare team

– Knowledge of evidence-based disease management

– Holistic approach to patient care

– Change agents

Challenges in the role transition to Population Coordinator

• Dramatic change in focus

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Challenges in the role transition to Population Coordinator

• Lack of understanding of the role

– Overlap with Coordinated Care Services

• Identification of patient population on Index and Readmission

– Access to data and data analysts

• No one left in the traditional CNS role to hand-off system responsibilities to

Facilitating patient

understanding of discharge

instructions following Total

Joint Replacement Surgery

Nadirah Burgess RN, MSN, ONC

HHS Announcement “In three words, our vision for improving health delivery is about better, smarter, healthier.” If we find better ways to pay providers, deliver care, and distribute information:

Encourage the integration and coordination of clinical care services

Improve population health

Promote patient engagement through shared decision making

Incentives

Create transparency on cost and quality information

Bring electronic health information to the point of care for meaningful

use

Focus Areas Description

Care

Delivery

Information

Promote value-based payment systems

– Test new alternative payment models

– Increase linkage of Medicaid, Medicare FFS, and other payments to value

Bring proven payment models to scale

We can receive better care.

We can spend our health dollars more wisely.

We can have healthier communities, a healthier economy, and a healthier

country.

Source: Burwell SM. Setting Value-Based Payment Goals ─

HHS Efforts to Improve U.S. Health Care.

NEJM 2015 Jan 26; published online first.

January 2015

12

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How To Make The LEAP

Volume Drives

Success

Value Drives

Success

13

What’s At Stake for Hospitals Billions of Dollars of Medicare Reimbursement at Risk

Medicare: = 47% of hospital inpatient revenue1

$5 billion of Medicare inpatient reimbursement at risk from

inpatient value-based programs in 2015 (Part A)

$1 billion in lost 2015 revenue

$7.5 billion of Medicare outpatient reimbursement at risk from

value-based reimbursement programs in 2015 (Part B)

10-50% of individual hospital net income is at risk

based on the size of their penalty and net income2

Commercial Payers:

In 2014, 40 % of commercial sector payments to doctors and

hospitals were made through value-oriented payment methods3

1 Healthcare Cost and Utilization Project (HCUP) 2011 2 Medicus Innovation Medicare Financial Analyzer Internal Analysis 3 Healthcare Affairs: National Scorecard on Payment Reform, Sept 30, 2014

14

Where Are We Headed

Cost-Based Reimbursement (1960s – 1980s)

Transition Period to Prospective Payment System (1990s)

Prospective Payment System (Late 1990s to 2009)

Transition Period (Current) • Payment Demonstrations

• ACOs

• Bundled Payments

Value-Based Purchasing

15

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Hospital Quality Reporting Programs Still Three Predominant Programs; but growing dollars at risk

VBP HRRP

HAC

1.00% 1.25% 1.50% 1.75% 2.00%

1.00%

2.00%

3.00% 3.00%

3.00%

1.00% 1.00%

1.00%

0%

1%

2%

3%

4%

5%

6%

7%

2013 2014 2015 2016 2017

HAC

HRRP

VBP

45% received VBP penalty

22% received HAC penalty

78% received a HRRP penalty

Penalties Received by Facilities FY 2015

Total Penalties Received

16

Hospital Readmissions Reduction

Program Conditions • Acute Myocardia Infarction

• Pneumonia

• Heart Failure

• Total Hip and Knee

• COPD

• CABG (FY 2017)

Excess Readmission Ratio’s in

ANY one of the clinical cohorts

results in financial penalties

Excess Readmission Ratio = Predicted /Expected

Values > 1.0 = Financial Penalties 17

Impact of OA/Joint Replacement

• In 2011, OA accounts for 47.4% of all arthritis-related hospitalizations.

• There were 757,000 total knee replacement procedures performed (OA accounted for 95%)

• There were 512,000 total hip replacement procedures performed (OA accounted for 80%)

• Estimated costs of TKR & THR, respectively, $28.5 and $13.7billion in 2009.

18

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What Is The Road Ahead

19

With regard to joint replacements…

• Complication adds approximately $1400 to the

cost of care

• Readmission will cost over $10,000

• Patients with complications are far less satisfied,

resulting in lower customer experience scores

for our hospital.

Evidence

• 5.7 percent of the cases had unplanned readmissions.

• 2.3 percent of those unplanned readmissions were

due to complications that occurred during the initial

hospital stay.

• 19.5 percent of unplanned readmissions were caused

by surgical-site infections.

• 10.3 percent of unplanned readmissions were caused

by delayed return of bowel function

JAMA. 2015;313(5):467-468

97 % of readmissions resulted from expected surgical

complications that occurred after a patient left the

hospital.

Underlying Reasons Associated With Hospital Readmission

Following Surgery in the United States

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Using clinical data prospectively collected for readmission information from 346 hospitals, we found that

readmissions were associated with new postoperative complications that surfaced after discharge in the

majority of cases, and 2 complications, SSI (19.5%) and obstruction or ileus (10.3%), were the most frequent

reasons for both early and late readmissions.

Our results demonstrate that surgical readmissions are related to well described complications of surgery.

Readmissions occurred relatively uniformly over the postoperative period, there was no particular peak post

discharge day on which readmissions occurred, and early and late readmissions had similar underlying

reasons. JAMA. 2015;313(5):483-495.

American College of Surgeons National Surgical Quality Improvement Program

NSQIP Registry Data (January 1, 2012, and December 31, 2012)

N= 498,875

N= 38,671

0pportunities to reduce readmissions

better coordination of care with the outpatient care team regarding expected

complications (eg, close monitoring of stoma output by clinic nurses)

minimizing fragmentation in post discharge care - ensuring that the physicians from the

outside hospital are in communication with the clinicians who treated the patient at the index

admission

the quality of education and discharge instructions provided to patients- Effective

patient education to set the postoperative expectations and warn about potential

complications

Ensuring a post discharge plan with clear discharge instructions and clear follow-up

some complications resulting in readmissions could be treated in the outpatient

setting rather than necessitating a readmission. For example, SSIs could be treated in an

advanced outpatient clinic where wounds could be opened and debrided and peripherally

inserted central catheters could even be placed to facilitate intravenous antibiotic

administration

JAMA. 2015;313(5):483-495.

the quality of education and discharge instructions provided to patients-

Effective patient education to set the postoperative expectations and warn about

potential complications

Baseline Data

30-Day Unplanned Readmissions Hospital Total

Total hip replacement GMC-D 4

GMC-L 6

Total hip replacement 10

Total knee replacement GMC-D 5

GMC-L 9

Total knee replacement 14

Grand Total 24

GMC FY14 READMISSIONS

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CURRENT CONDITION

PROBLEM ANALYSIS

Problem:

Facilitating patient

understanding of

discharge

instructions to

reduce known

post-operative

complications

and/or unplanned

readmissions for

Total Joint

Patients

(Hip and Knee)

Limited time to plan

for discharge

teaching

No consistency in Discharge

Teaching Content

No formal process at discharge to assess

patient health literacy/comprehension or high

risk for complications/readmission

Ishikawa diagram

FISHBONE:

Limited accessibility

of discharge teaching

post discharge

No standard teaching protocol/method

Options are customized for each patient

no reinforcement or monitoring of teaching

Transition of staff/leadership

Transition from paper to electronic

Lack of coordination of discharge timing

RN has multiple patients

RN responsible for other non-discharge related tasks (e.g., remove IV, pt. belongings, etc)

Waiting on multiple other providers for clearance

Waiting on family or other care givers

Strictly a paper process

Instructions on paper could get lost

Questions post discharge during business hours only

Assessment done on admission only

Variation in admitting and discharge RN

Discharge content generated electronically

Assessment not included in electronic process

Communication about complications not part of discharge content

TARGET CONDITION

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COUNTERMEASURES

• Standard work

• Visual controls

(Joint class, inpatient, post-

discharge follow up)

IMPLEMENTATION PLAN 1. Create standard work– Total Joint “Discharge Education Toolkit”

• “Goals to Discharge”

• “Key points and Teach Back questions” related to known

complications and reasons for readmission

2. Integrate “Discharge Education toolkit” into pre-op education class,

inpatient teaching material, patient discharge class curriculum.

3. Reactivate the Patient Discharge Class for Total Hip and Total Knee

patients

4. Conduct staff education about new standard work/teach back process

to include role play in education.

5. Teach Back Observation Monthly Audits using best practice Teach

Back Observation tool

HCAHPS Domain Scores Ortho Patients - Percent ALWAYS

40%

60%

80%

100%

8-1-13 thru 7-31-14 8-1-14 thru 7-31-15

PI Efforts have focused on Pain

Management and Discharge

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Performance Improvement Efforts Pain Management (Target = Top Quartile Performance)

40

60

80

100

PainAggregate

PainControl

StaffEfforts

Percent Always

8-1-13 thru 7-31-14

8-1-14 thru 7-31-15

81 81 76

40

60

80

100

PainAggregate

PainControl

StaffEfforts

Percentile Rank

8-1-13 thru 7-31-14

8-1-14 thru 7-31-15

Target

Performance Improvement Efforts Discharge (Target focus is reducing readmissions)

94 93.2 93.8

95.6 93.9

97.2

80

90

100

DischargeAggregate

Staff talkedabout help

needed

Understandsymptoms to

look for

Percent Always

8-1-13 thru 7-31-14

8-1-14 thru 7-31-15

97 96

92

98 97

98

80

90

100

DischargeAggregate

Staff talkedabout help

needed

Understandsymptoms to

look for

Percentile Rank

8-1-13 thru 7-31-14

8-1-14 thru 7-31-15

30- Day Readmission GMC

2.78%

2.68%

2.62%

2.64%

2.66%

2.68%

2.70%

2.72%

2.74%

2.76%

2.78%

2.80%

FY14 FY15

TKA 81.54

TKA 81.54

Benchmark

Data Source- Crimson July 2014-June 2015

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30- Day Readmission GMC

3.54%

2.33%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

FY14 FY15

THA 81.51

THA 81.51

Benchmark

Data Source- Crimson July 2014-June 2015

Future Plan

• Integrate Total Joint Discharge Education

Toolkit on the GMC Total Joint Program

website

• Developed online pre-op patient

education module

References • Underlying Reasons Associated With Hospital Readmission Following

Surgery in the United States. JAMA. 2015;313(5):483-495.

• Unplanned Readmission After Total Joint Arthroplasty: Rates, Reasons, and

Risk Factors. J Bone Joint Surg Am 2013;95:1869-1876

• Boutwell, A. Griffin, F. Hwu, S. Shannon, D. Effective Interventions to

Reduce Rehospitalizations: A Compendium of 15 Promising Interventions.

Cambridge, MA: Institute for Healthcare Improvement; 2009

• www.IHI.org : Engage Patients and Families in Care;Person- and Family-

Centered Care;Communication “Always Use Teach Back!”

• Reducing Complications and Readmissions for Joint Replacements –

Accelero Health Partners –Unity Point Health St. Luke’s Hospital, Webinar

December 2014

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A Multifaceted Approach to

Reducing 30-day Readmissions

in the COPD Population

Pam Garrett MN, APRN, ACNS-BC,CCRN, CMSRN

Impact of COPD

• 3rd leading cause of death in US

• 15 million adults in US with COPD dx.

• Estimated 30 million have evidence of

impaired lung function

• COPD is a leading cause of disability

• 81% of COPD patients have 6 or more co-morbid conditions – Osteoporosis, hypertension, heart failure, diabetes, depression,

anxiety, sleep apnea, cancer… (COPD Foundation Survey)

COPDfoundation.org

Impact of COPD

• In 2009, COPD caused • 8 million office visits

• 1.5 million ED visits

• 715,000 hospitalizations

• 134,000 deaths

• COPD costs the US government $40-70

billion in direct & indirect costs per year – AECOPD account for most of the morbidity, mortality

and costs associated with COPD

– Hospitalization due to AECOPD accounts for

50% of the cost of managing COPD

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CMS Readmission Penalties

• In October 2014, the Hospital Readmission Reduction Program (HRRP) was extended to include COPD

– Unlike HF, there were no COPD-specific studies/guidelines in the literature to guide hospitals on readmission reduction strategies for the COPD population

– Very limited evidence on readmission risk factors and reasons for readmission specific to the COPD population

Other challenges with the COPD

Outcome Measure

• No disease markers for inclusion/exclusion of

the diagnosis

• COPD cohort is defined not only by a primary

diagnosis of COPD, but also as a secondary

diagnosis if the primary is respiratory failure: J80 Acute respiratory distress syndrome

J9600 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia

J9620 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia

1J9690 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia

1R092 Respiratory arrest

(Specifications Manual for Nat'l Hospital Inpatient Quality Measures)

Consequences of Readmissions

• Hospital

– CMS Penalty -> up to 3% of all Medicare reimbursement

• Patient & Family

– Decreased functional level

– Reduced life expectancy

– Caregiver strain

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Figure reproduced with permission. Copyright 2009 Lancet Publishing Group

In the beginning…AKA 2014

• CNS for Medical Services becomes the Pulmonary Program Coordinator

• Goals

• Reduce 30-day readmission rate to <15%

• Reduce the ALOS

• Baseline data:

• GMC COPD Readmission FY14 19.4%

• National average – 20.7% • www.Medicare.gov/hospitalcompare

Data period 7/1/2010-6/30/2013

Why are COPD patients

readmitted?

• Readmission Interviews – AECOPD vs other cause

– Did they have a follow-up visit with provider?

– Did they fill their prescriptions?

– Number of admissions and ED visits in the past 12

months

– Co-morbidities

– Patients perception re. how the re-hospitalization

could have been avoided

– Compliance issues

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26

11

1

68.4%

97.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0

5

10

15

20

25

30

35

Disease Related Patient Related Physician

Related

Nu

mb

er o

f p

atie

nts

Categories of Reasons for Readmission

Potential Cause(s) of Readmission on Interview

Patient related factors;

Medication and Diet Non-compliance

Environment at DC

Smoking

Social Isolation

Economic Factors

Cultural Factors

Language Barrier

Denial/Psychiatric issues

Disease specific factors

Arrhythmia

Anemia

BP-high and low

Diabetes

Electrolytes

Ischemia

Infection

Optimal medical therapy

Re-synchronization

Natural history/progression of disease

Physician Factors

Inadequate DC Instructions

Inadequate Diuretic Discharge Dose

Discharged too early

Duplicate medications

Failure to reconcile to ambulatory care

Lack of consultation (Cardiology/Palliative Care)

COPD Readmission Interview Survey Analysis 2014 (April, May, June 30-Day Readmissions)

(n=38)

Prepared by P Jones 15Oct2014 Privileged and Confidential: Prepared for a Peer Review Committee pursuant to Title 31, Chapter 7 of the Official Code of Georgia

Gather the troops!

• COPD Team

– Physician champions: pulmonologists; hospitalist; ED

– Administrative sponsor: Director of Med-Surg Nursing

– Multidisciplinary membership

• Coordinated Care: CM, SW, Transitions Coordinator

• Nursing: clinicians, managers, staff

• Respiratory Care; Pulmonary Rehab.

• Pharmacy

• Dietician

• Providers

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Team Priorities

• Ensure provision of EBP/Best Practices

– Review and revision of the standardized COPD

admission orders

• Review Readmission & LOS data and identify

opportunities for improvement and actionable

items

Identification of Trends

• Medication noncompliance

• No PAP therapy

• Discharged without services

• Smoking

• Lack of understanding of the disease & disease management

• Failure to schedule/keep provider follow-up appt.

• Multiple co-morbidities

• Social Isolation

Medication Challenges • Compliance

– Not filling prescriptions &/or refilling Rx

– Not taking medications as prescribed

• Cost

– Average control inhaler $250-500. per month

• Patient reported his discharge prescriptions totaled $1700. (for one month supply)

• Knowledge

– Lack understanding of rescue vs control medications

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Improving Medication Compliance

• Medication Education:

– nurse and RT to ensure every pt can identify rescue

and control medication, and state appropriate use

• Educating Coordinated Care team on inhaled

medication issues

– changed their intake question to specifically ask if pt

had filled inhaler Rx

• Identified Prescription Assistance Programs for

the most commonly prescribed inhalers

– Enrolled in the Spiriva Hospital-to-Home Program

PAP therapy

• Identification of patients – Educated Case Managers to look for diagnosis of

chronic hypercapnic respiratory failure

• Collaboration with DME providers – Initiate therapy 24 hours or more before discharge

– RT available 24/7 to patients at home

• Staff education: hospital and SNF – Positive effect on quality of life

– Encourage daytime use

Disposition Planning

• Evaluation of patient resources to manage care independently

• Referrals to appropriate HHC agency:

– Telehealth monitoring for HF

– Respiratory disease mgt. program

– Bridge to hospice services

• High risk for readmission

– Palliative care referral

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Transition Management

• Nurse Navigator – Education

– Post-discharge phone calls (initially)

• Transition Coordinators – Post-discharge phone calls within 48 hours

– Home visits

– Home physician visits

• Collaboration with HHC and SNF – Weekly conference calls to discuss readmissions

– Staff education on disease management

Disease Education • Staff Education

– COPD Jeopardy

• Patient Education

– Standardized COPD Education materials

– Created COPD teach-back poster and brochure on activity and exercises for the COPD patient

– COPD Zones

• reinforced in the post-discharge phone call

– Smoking cessation education

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Provider Follow-up • Informed pulmonology practices of CMS Transitional

Care Management Services

– Higher reimbursement for office visits post-hospital discharge

– Patients must be contacted within 48 hours and seen within 7 or

14 days

• Educated nurses to instruct all patients with AECOPD to

see provider within 7-10 days of hospital discharge

• Encouraged patients to make appointments prior to

discharge

• Instructed patients to call Navigator/Transitions

coordinator if they had difficulty getting

an appointment

Qualitative Improvements

• Collaborative effort between disciplines – One pulmonary group hired 2 NP’s so their patients could be

seen within 7 days of hospital discharge

• Increased awareness of factors contributing to

readmissions – Increased physician awareness of the cost of the prescriptions

and the burden on the patient

– CM initiating the discussion regarding PAP early during an

admission

– Increased nursing awareness of the need for pt education

– Quality of “service” provided by DME companies that provide NIV

Quantitative Measures of Success

• COPD Readmissions – Readmission rate for FY14 19.4%

– Readmission rate for FY15 16.7%

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Hospital Compare Data 2012-2015

References

Criner, G.J., Bourbeau, J., Diekemper, R.L., Ouellette, D.R., Goodridge, D., Hernandez, P.,...Stickland, M.K. (2015). Executive Summary: Prevention of Acute Exacerbation of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest. 147(4), 883-893. doi: 10.1378/chest.14-1677

Fan, V.S., Gaziano, J.M., Lew, R., Bourbeau, J., Adams, S.G., Leatherman, S.,...Niewoehner, D.E. (2012). A Comprehensive Care Management Program to Prevent Chronic Obstructive. Pulmonary Disease Hospitalizations. Annals of Internal Medicine. 156(10), 673-683.

Mannino, D.M., & Thomashow, B. (2015). Reducing COPD Readmissions: Great Promise but Big Problems. Chest. 147(5), 1199-1201. doi: 10.1378/chest.15-0380

Playbook for Reducing COPD Readmissions: Eleven Strategies for Strengthening Inpatient and Post-Discharge Care. (2015). The Advisory Board Company. Retrieved from www.advisory.com

Shah, T., Churpek, M.M., Perraillon, M.C., & Konetzka, R.T. (2015). Understanding Why Patients With COPD Get Readmitted: A Large National Study to Delineate the Medicare Population for the Readmissions Penalty Expansion. Chest. 147 (5), 1219-1226. doi: 10.1378/chest.14-2181

Struck, F.M., Sprooten, R.T.M., Kerstjens, H.A.M., Bladder, G. Zijnene, M., Asin, J.,...Wijkstra, P.J. (2014). Nocturnal non-N aside ventilation in COPD patients with prolonged hyper apnea after ventilators support for acute respiratory failure: a randomized, controlled parallel-group study. Thorax. 69, 826-834. doi: 10.1136/thoraxjnl-2014-205126

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Challenges in

Achieving

Compliance

with Quality

Core Measures

For Stroke

Susan M. Gaunt, MS, APRN, ACNS-BC, ANVP, CCRN, CNRN

Impact of Stroke

• Each year, ≈795,000 Americans have a stroke

• 5th Leading cause of death in the US

• Major cause of disability

• Annual costs exceeds $73 billion

Gwinnett Medical Center Statistics

• Advanced Primary Stroke Center certified

• Refer to Comprehensive Stroke Center for

Endovascular care

• Served 825 stroke patients in 2016

• 2 Neuro Hospitalists cover both facilities

• 115,000 Emergency Department visits

2016

• Compete with Trauma and STEMI care

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Stroke Core Measures

STK-1 VTE Prophylaxis by end of hospital day 2

STK-2 Discharged on antithrombotic

STK-3

Discharged on anticoagulation therapy for atrial

fibrillation/flutter

STK-4

Thrombolytic therapy for patients presenting

within 2 hours of symptom onset

STK-5 Antithrombotic therapy by end of hospital day 2

STK-6

Discharged on statin medication for LDL > 70

or history of dyslipidemia

STK-8 Patient/family stroke education

STK-10 Assessed for rehabilitation

Time is Brain

• For every 15 minute reduction in time to

administration of Alteplase/tPA the

likelihood of a good outcome improves for:

– Walking independently at discharge

– Discharging to home

– Less hemorrhagic transformation

– Decreased in-hospital mortality

Population Management

• Data collection, comparison & analysis

• Incorporate evidence-based practice

• Implement process improvement

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IV tPA within 60 Minutes

60.60% 65%

61.5%

76%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

GMC % within 60 min. Ga Hospitals within 60 min

2013

2014

2015

Get With the Guidelines-GWTG data

Gather the Troops

• Multidisciplinary Stroke Team:

– Stroke Medical Director & Neuro-hospitalist

– EMS

– ED (physicians, leadership, nursing)

– Radiology (leadership and radiologists)

– Laboratory management

– Pharmacist

– CNS & Quality Coordinator

Evidence-based Practice

• Literature

• Expert Opinion

• Professional contacts in the community

(Georgia Stroke Professional Alliance)

• Outcomes

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Process Improvement

• Map current process

• Analyze best practices to see what is

feasible

• Educate changes

• Implement

• Evaluate

• Celebrate

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Opportunities

• Witness/family contact information

• Earlier Neurology consult

• Pharmacist response to Stroke Alert

• Pre-mix Alteplase/tPA

• Un-couple CT and CTA Head and Neck

• Not delaying thrombolytics for lab results

or consent

Simultaneous Process Changes

• EMS to bring witness/contact information

• Neurology called after initial assessment

• Neurology decides treatment plan

• Thrombolytic pre-mixed by pharmacist

• Thrombolytic given after CT

• Patient returns to CT for CTA

• Thrombolytic not held for consent or lab results

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CNS Support

• Emergency Department Stroke Alert

Response

• Feedback

• Recognition

Door to Needle Time Results

61.5%

84%

40%

76%

82.9%

51.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2015 < 60 2016 < 60 2016 < 45

Gwinnett

Ga Hospitals

Minutes

Improved Average Door To

Needle Time

2015

N=52

2016

N=82

GMC 65.2 min 49.7 min

GA Hospitals 51.1 min 48.1 min

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Door To Needle Time

Awards!

References • D. Mozafarian, E. Benjamin et al. (2016). Heart Disease and Stroke Statistics-2016 Update. A

Report From the American Heart Association. Circulation. 2016; 133:e38-360.

• Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014; 384:1929

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