stroke level iii hospital data collection webinar · 1. stroke program medical director with...

Stroke Level III Hospital Data Collection Webinar Sheryl Martin-Schild, MD, PhD, FANA, FAHA

Stroke Medical Director for the State of Louisiana Louisiana Emergency Response Network (LERN)

LERN Stroke Strategic Priority

• Develop a statewide system of stroke care to improve outcomes for Louisiana citizens regardless of where they live in the state.

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LERN

AHA/ASA: Expanded Systems of Care 12 states and DC have enacted policies around the recognition of stroke facility designations

D.C.

LERN

How are LERN Stroke Hospital Levels defined?

• Level I = Comprehensive Stroke Centers • Level II = Primary Stroke Centers • Level III = Acute Stroke Ready Hospitals • Level IV = Stroke Bypass Hospitals

LERN

2 16 -> 15

LERN

Hospital Criteria LERN Level III

ER staffed by physician 24/7 Evaluates within 10min and contacts neurological expertise within 15min of arrival

Neurological expertise Within 15 min of arrival, by phone or telemedicine

CT scan available 24/7 within 25min of arrival

And have scan interpreted within 45min of arrival

Labs resulted <45min of arrival CBC, platelets, PT/INR/PTT, and chemistry

Proficient tPA delivery Able to administer tPA within 60min of arrival; appropriate transfers for higher level

Protocols for stroke care Guidelines, algorithms, critical care pathways, NIHSS training; plan for secondary transfer

Quality control Involvement in GWTG-Stroke or submission of data to LERN

LERN

The Joint Commission requires the following additional components for certification as an Acute Stroke Ready Hospital:

1. Stroke Program Medical Director with sufficient knowledge of cerebrovascular disease.

2. Acute Stroke Team available 24/7, at bedside within 15 minutes; may be comprised of a physician, nurse practitioner, or physician assistant and a nurse who have at least 4 hours of stroke education annually

3. Access to protocols used by EMS 4. Access to neurosurgical services within 3hrs of request onsite or

through transfer; written transfer agreement 5. ED staff education at least twice a year 6. Provision of education to prehospital personnel 7. Clinical performance measures – organization chooses 4 measures,

at least 2 are clinical measures related to clinical practice guidelines 8. Maintenance of a stroke patient log

LERN

Who monitors performance of LERN Stroke Hospitals ?

• Level I = Comprehensive Stroke Centers – TJC, DNV

• Level II = Primary Stroke Centers – TJC, DNV, HFAP

• Level III = Acute Stroke Ready Hospitals – TJC or HFAP (if certified) – LERN

• Level IV = Stroke Bypass Hospitals – Not applicable

LERN

How is LERN data submission different than participation in GWTG-Stroke?

• LERN data elements are exclusively focused on what happens in the ED – Efficient evaluation, treatment, and triage

• GWTG-Stroke is an in-hospital program for improving delivery of optimal stroke care based on treatment guidelines – Includes the most LERN data elements – Many other benefits of participating

• The quarterly stroke data report card provides tailored feedback and recommendations.

LERN

GWTG-Stroke user

If a GWTG-Stroke participating center wants to receive the LERN feedback report…

– Query the recorded LERN data elements from GWTG-Stroke

– Transfer the fields into the stroke data point entry form

– Submit for review

Most of the work was already done!

LERN

Region 1

Dr. Sheryl Martin-Schild

Submitting data to LERN?

PSC

PSC

Yes

No

CSC No

No

PSC/Yes

CSC

Yes

PSC

No

LERN

Region 2

Dr. Joseph Acosta


PSC

Yes

No

No

PSC

Yes

Pending….

Yes

Yes

LERN

Region 3

Dr. Digvijaya Navalkele


n/a

Yes

Yes

n/a Yes

No

No/GWTG

Yes

Yes

No/GWTG

No

LERN Submitting data to LERN?

No

Region 4 n/a

Yes

n/a

No

No

No

PSC

Dr. Leo n/a DeAlvare Yes

No

n/a

PSC

n/a

Yes

n/a

n/a

LERN

Region 5 Submitting data to LERN?

n/a

n/a

Yes

n/a

Pending

n/a

No

n/a

n/a

Yes

?

LERN

Region 6

Dr. Gonzalo Hidalgo


n/a

n/a

n/a

No

PSC

No

n/a

PSC

n/a

Yes

2

LERN Submitting data to LERN?

Region 7 n/a

n/a

Yes

No

n/a

PSC

Yes

Yes Dr. Oleg Chernyshev

n/a

n/a

Yes

PSC

n/a

n/a

No/GWTG

No

Regi?on

8


n/a

n/a

n/a Yes

No

No

n/a

n/a

n/a

Dr. Jeffrey Harris

n/a

n/a

n/a

No/GWTG

LERN

Region 9

Dr. Ramy El Khoury


n/a

Yes

PSC

n/a PSC

PSC

No

Yes

n/a

n/a

PSC

No/GWTG

LERN

• Example of sustained improvement.

LERN

• What is taking so long after labs and CT?

LERN LERN data submission

EQuIPPED = Electronic Quality Improvement Participating Emergency Department

LERN

LERN data submission the problem

• Some centers set the standard • Some centers are demonstrating improvement • Some centers have consistent problems • Some centers have submitted very few cases

All of these centers were considered “confirmed”

LERN

To address the problem….

The LERN Board approved a change in nomenclature to EQuIPPED = Electronic Quality Improvement Program Participating Emergency Department

All report cards will be sent to CEOs Action plans will be required to maintain EQuIPPED status • Require improvement within next 2 quarters

The data entry form

Which patients get entered into the spreadsheet?

ALL patients seen in the ED with suspected stroke.

However, if a patient arrives >3 hours after last seen normal, the last field which needs to be populated is Column F (Arrival Time at Door).

• The hospital identifier is a 3 letter code assigned by LERN.

• The hospital ID should only be entered in cell A5. • It will automatically fill in all after that,

as cases are entered. • If you are trying to enter the ID

in any other cell, it will appear blank. • Enter the ID in A5 only.

• Q will = 1, 2, 3, or 4 based on 1 = Jan – March 2 = April – June 3 = July – September 4 = October – December

• Do not enter Q • Do not enter 01, 02, 03, or 04 • YY will equal the last 2 digits

of the year (currently 17) • Q1 of 2017 should be

entered as 1-17 • not Q1-17 • not 01-17 • not 1-2017

• The date which should be recorded is the date the patient arrives to the hospital.

• The format should be Mo/Da/Yr.

• For example, January 1st, 2017

should be recorded as 01/01/17. • Two digits/two digits/two digits. • Not 1/1/2017. • Not Jan-01-17.

• The patient ID # should be a “Dummy ID” without any identifier, yet facility-dependent.

• Patient identifiers should not be included in the dataset to LERN.

• Please use the Hospital Identifier, followed by the quarter, followed by 001.

• For example, if your hospital identifier is CCC, and it is 3rd quarter of 2017, your first patient's Dummy ID should be: CCC-3-17-001. The next patient would be: CCC-3-17-002, and so on.

• LSN is the time (military time) that the patient was last known to be at his or her normal neurological condition.

• LSN time = the time of onset for: • a person who was awake at

onset and can provide his or her own history

• a person with witnessed onset. • If the LSN time is unknown, leave

the cell blank. • If the LSN time is the day prior

and more than 3 hours before the time of arrival, simply enter “>3 hours.”

• If the LSN date is before the arrival date and the patient arrives less than 3 hours after LSN, the earlier date will be assumed.

• For example, if the patient was LSN at 22:00 on 02/02/17 and arrives at 00:20 on 02/03/17, it will be assumed that the patient arrived 2 hours and 20 minutes after LSN on the date – 1.

Arrival Time at Door - This is the time (military time) that the patient was first acknowledged as being present at the LERN Level III Stroke Center. • If the patient arrives by

ambulance, this is the time the ambulance arrives at the LERN Level III Stroke Center.

• If the patient arrives by private vehicle or as a walk-in, this is the time stamp on the ED triage form.

LERN

If the arrival date/time is > 3hours after the date/time of LSN….

You are DONE submitting data for

this patient NO further data elements should

be recorded

LERN

Why register patients whose arrival date/time is > 3hours after the

date/time of LSN? • Determine the % of all stroke patients who

present to the hospital within the “window of opportunity”

• Determine the hospital’s tPA treatment rate – Missed opportunities? – Track the proportion presenting “in the window”

over time as you provide community education.

• Let’s take an example of a patient who develops symptoms while in the ED or had resolution (TIA) and then recurrence while in the ED… the LSN time would be after the arrival time.

• A patient had L sided weakness which had resolved before arrival at 23:00 on 02/03/17. The nurse sees the patient normal at 00:30 on 02/04/17. The nurse finds the patient with L sided weakness at 01:00.

• If the true arrival time was documented, it would be assumed that the patient presented 22 hours after onset of L sided weakness and question administration of tPA.

• To address this scenario, if LSN is after arrival, change the Arrival Date in Column C and Arrival Time in Column F to = date and time when the patient was LSN. • The Date recorded in Column C

should be 02/04/17. • LSN should be 00:30. • Arrival time should be when

symptoms were noted (01:00).

• This is the time (military time) the ED physician first documents a face-to-face encounter with the patient with suspected stroke who presents within the first 3 hours after last seen normal.

• If the patient presented > 3hours after LSN, don’t record anything!

• The goal is 10 minutes from the Time of Arrival to the Emergency Department until the Time the ED physician evaluates the patient.

• The median time among patients presenting < 2hours is 5min.

• Communication with Neurological Expertise Time is the time the neuro expert was first reached to make them aware of the stroke code.

• If the patient presented > 3hours after LSN, don’t record anything!

• The goal is 15 minutes from the time of arrival to time the expert is contacted.

• Among LERN Level III EQuIPPED centers, the median time was 34 minutes for patients presenting <2 hours from LSN.

• Telestroke “readiness” is a barrier. • It is all about the door-to-needle time.

• 3% neuro • 2% intens

• LERN recognizes that physicians have variable experience and expertise with acute stroke management

• A neurological expert may be a provider other than a neurologist

• Emergency medicine • Hospitalist • Intensivist • Neurosurgeon • Nurse Practitioner • Physician Assistant • Resident Physician

• Among LERN Level III EQuIPPED centers, 85% responded to this data element

• 77% neurologist • 18% emergency medicine

If the patient presented > 3hours after LSN, don’t record anything!

surgeon ivist/hospitalist

•

Time CT Performed • This is the time (military time) of the time


stamp on the baseline CT scan of the head. The goal is 25 minutes from the Time of Arrival to the Emergency Department.

• Among LERN Level III EQUiPPED centers, the medium time was 14.5 minutes for patients presenting <2 hours from LSN.

Time CT Interpreted • This is the time (military time) when the

interpretation of the baseline CT scan of the head becomes available

• Provider credentialed for interpretation of neuroimaging at the center.

• The goal is 45 minutes from the Time of Arrival to the Emergency Department.


Time to Completed Labs • This is the time (military time) when appropriate

laboratory values are available for patients with suspected stroke who present within the first 3 hours after LSN.

• AHA/ASA recommends CBC with platelet count, PT/INR/PTT, and chemistry with glucose.


• The goal is 45 minutes from the Time of Arrival to the Emergency Department Door.


Time of tPA Bolus • This is the time (military time) when the bolus of tPA

is pushed IV in the patient with suspected stroke. • The goal is 60 minutes from the Time of Arrival to

the Emergency Department and represents the “Door-to-Needle time”.

• Every minute matters - up to 2 million brain cells are destroyed each minute during a large artery occlusive stroke.

• The effectiveness of tPA depends on early administration.


• Systematic improvement in the Door-to-Needle time should be a priority for all LERN Level I, II, and III Stroke Centers.

• LERN recognizes the new target door-to-needle time of 45min (AHA Target Stroke).

• Will work with your center to trim your DTN time

FDA – Contraindications and Warnings & Precautions AHA/ASA 2013 – Exclusions and Relative Exclusions AHA/ASA 2015 – Scientific Rational paper

Among LERN Level III EQuIPPED centers, the most common cited reason were: •Outside of the window – 49.1% • TIA – 10.5% •Hemorrhage on CT – 4.3% Among the remaining patients: • Not documented – 37.6% • Minimal deficit – 15.8% • Unable to treat within 4.5hrs – 8.1% • Refusal – 7.7% • Other - 5.7% • Coagulopathy – 4.3% • Seizure – 4.3%

GWTG-Stroke has an option to select justifiable reasons for a delay in tPA administration • Patients with justifiable reasons do not contribute to

median times LERN has added this data element and recognizes these barriers to efficient tPA use: • Hypertension requiring aggressive control with IV

medications • Management of concomitant emergent/acute conditions • Further dx evaluation to confirm stroke in patient w/

blood glucose <50, seizures, or major metabolic disorders thought to be mimics

• Delay in determining eligibility • Timeline evolved • Need to obtain additional information

• Patient/Family Consent • Delayed diagnosis • Equipment related delay

L O U III SI A N A

" MERGENCY RESPONSE N TWO K STROKE DATA POilN T STATISTIC

2

Door to ED d:OC in hctUTS & minut es

3

D oor to r,kuro logic:aI Exp er t ise il'l hours & m Jnute:s

Do.or to CT Perform ed in hours& minutes

DODrto.CT Inte rpret ed in hours& m

inute :sc

Door ta Complet ed

Labs in hours & minutes

S6of pat ients Wit h I.a t:ts m rnp te.re d' wit hin 4 S m in of

arrival

p.at i ents arr ive,d •1it h i n 2 hours of

LSN

' 0:11 0:24 0:47 i

6

8

0:48 '

: 1:16

WALUE!

1 :51 LSNlw itihin 2 hours

' ! W ALUE!

' jWALUE!

' 0:20 0:31 0:17 L3 os c,omplet e w/ in 4 S m inut e1

'' ...''',

LOUI SIANA

0:42 ,t P/\ w / in 60 minut e. t PA w,/in 3 hours , ! LSNlw itih in 2 h our s. ' '

' ifNALUE!

, EMERGENCYRESPONSENETWORK STROK NS AND PERCENTAGES

P nP ?

Total

Number of

Patients

# of patients arrived within 2 hours of LSN

Door to ED doc MEDIAN time

in hours & minutes

Neurological

Expert ise MEDIAN time

in hours&

Performed MEDIAN time

in hours & minutes

Interpreted MEDIAN time

in hours & minutes

Door to Completed

Labs MEDIAN time

in hours&

Door to Needle MEDIAN time

in hours & minutes

% of patients with labs

completed within 45 min

of arrival

% patients treated with tPAwho are treated within

60 min of

% patients receivi ngtPA within 3 hours

of LSN who arrived withn 2

Doo r to

;i, p,at ients t reat BCI

-%p,at ients

.r,eceiving t f'A Ne edl e wit h t PA w ho·a,r e i t hin 3hoursof

inhour. s& t neatB d' w ithin '60 LSr-lwh arr ived mi nut es m in of arr iva l Wit hn 2 hoursof

LSN

minutes minutes arrival hours of LSN 6 6 0:11 0:37 0:26 0:39 0:25 1:00 67% 60% 50%

LERN

Quarter Patients Patients Patients % of all % of patients presenting

:::2hrs from LSN

treated with tPA

Mean registered :::2hrs from

LS.N tre.ated with

tPA patients

registered who·were

doo:r-to- needle time

treated with tPA

Q2 2016 22 7 5 31.8 71.4

Q3 2016 10 7 5 5(}.0 71.4

The target . time has historically been <60min; the American Heart Association/American Stroke Association (AHA/ASA) is now reconunending a target time <45min from arrival to treatment. h1 EQuIP PED Level ill hosp itals, the median door -to-needle (DTN) time is 70min. Only 40% of treated patients received alteplase within 60min; ouly 16% were treated within 45min.

LERN

Tips for data collection

• Designated person/s • Register in real time • Template for documentation for elements

that are difficult to determine retrospectively – LSN – Arrival of ED doc – Communication with

neuro expertise – Reason why tPA delayed

LERN

Summary

• Patients deserve to get what a hospital says it can provide

• Quality improvement program participation is necessary to reach the standards – Becoming EQuIPPED is a simple mechanism

• LERN data submission is not labor-intensive and not intended to be punitive

LERN

QUESTIONS???

Special thanks to Elizabeth Marcotte, RN, SCRN, CBIS, Neuroscience Program Coordinator for OLOLake Regional Medical Center, for content review and feedback on this presentation

stroke level iii hospital data collection webinar · 1. stroke program medical director with...

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