Accreditation Canada - Stroke Distinction Scorecardontariostrokenetwork.ca/wp-content/uploads/2013/10/LH-OSN-Stroke... · Stroke – Non-Alteplase/Post Alteplase (Greater than 24

Accreditation Canada - Stroke Distinction Scorecard

January - June 2015

Indicator

Threshold

Preferred

Indicator

Direction

Q4

14-15

Q1

15-16Q2 15-16

April -

Sept. 2015

≤ 14 days ↓ 4.7 4.2 4.0 4.0

≥ 14 days ↑ 16.9 15.3 16.8 15.8

Rate 86.6% 91.5% 91.5%

≥ 85% ↓

54 54

59 59

# of acute ischemic stroke and hemorrhagic stroke clients who receive dysphagia screening in the ED, acute inpatient services or in

inpatient rehabilitation. 58

Total # of acute ischemic or hemorrhagic stroke clients admitted to ED, acute inpatient services, or inpatient rehabilitation. 67

Rate 94.0% 98.3% 95.9%

≥ 80% ↓

59 116

60 121Total # of stroke clients admitted to a hospital (TIA, ischemic, intracerebral hemorrhage). 67 61

93.4%

6

Rate 68.5% 72.6% 72.6%

≥ 90% ↓

130 130

179 179

≤12% ↓

6 14

240 491

6. Readmission to acute care for stroke related causes# of acute stroke and TIA clients that are discharged alive from acute inpatient care who are then readmitted to hospital with a new

stroke or TIA diagnosis between 14 and 90 days of index acute care discharge. 4

Total # of stroke clients discharged alive from the emergency department or inpatient care following an index stroke event. 218

Total # of stroke clients discharged alive from an acute services hospital following an index stroke event.

Rate

> 7% ↑

22 36

134 261

11.9% 16.4% 13.8%11.0%

2. Proportion of ischemic stroke clients who receive acute thrombolytic therapy (tPA)

# of ischemic stroke clients who receive acute intravenous thrombolysis at stroke site. 13

# of all ischemic stroke clients presenting to the stroke site. 109

Number of stroke clients who died while in hospital (ED or inpatient) for an acute stroke event within the first 30 days of hospitalization.

Number of all stroke clients who are admitted to the emergency department and/or acute inpatient services.

5

223

14

127

Acute Stroke Service

2.2%

7

248

2.8%

14

506

2.8%

Indicator

Rate

< 22% ↓

1. Stroke/TIA mortality rates

7

258

2.7%

3. Time to administration of acute thrombolytic agent

Number of clients receiving IV or V/IA tPA within 60 minutes of hospital arrival (Based on ED triage time) 7# of ischemic stroke clients presenting in ED or inpatient services who receive tPA through an intravenous or combined intravenous and

intra-arterial route. 11

5. Length of stay in an acute care hospital setting for clients admitted following an acute stroke event

4a. Proportion of clients treated on dedicated stroke unit# of stroke clients admitted to hospital and treated in an acute stroke unit, a rehabilitation stroke unit or an integrated stroke unit at any

time during hospital stay. 78

Total # of stroke clients admitted to a hospital (TIA, ischemic, intracerebral hemorrhage). 92

Rate 84.8% 84.1% 86.5%

≥ 75% ↑

116 225

138 260

Rate 63.6% 60.0%

123

8. Proportion of acute ischemic stroke and TIA clients prescribed antithrombotic therapy# of ischemic stroke/TIA clients who are discharged from the emergency department or inpatient acute services or inpatient

rehabilitation services on antithrombotic therapy. 113

Total # of ischemic / TIA stroke clients discharged alive from the ED, acute services or inpatient rehabilitation. 165

Rate 34.1% 41.7% 38.1%

≥ 15% ↓

58 104

139 273134

34.3%

9. Proportion of clients with initial dysphagia screening at admission# of acute ischemic stroke and hemorrhagic stroke clients who receive dysphagia screening in the ED, acute inpatient services or in

inpatient rehabilitation. 32

Total # of acute ischemic or hemorrhagic stroke clients admitted to ED, acute inpatient services, or inpatient rehabilitation. 86

Inpatient Stroke Rehabilitation Services1. Proportion of clients treated on dedicated stroke unit

# of stroke clients admitted to hospital and treated in a rehabilitation stroke unit 63

Rate 37.2% 45.5% 45.5%

≥ 85% ↓

40 40

88 88

57

2. Length of stay in an inpatient rehabilitation setting for clients admitted following an acute stroke event

3. Proportion of acute ischemic stroke and TIA clients prescribed antithrombotic therapy

Median length of stay in rehab (days)

# of ischemic stroke/TIA clients who are discharged from the emergency department or inpatient acute services or inpatient

rehabilitation services on antithrombotic therapy. 56

Total # of ischemic / TIA stroke clients discharged alive from inpatient rehabilitation. 58

4. Proportion of clients with initial dysphagia screening at admission

Rate 96.6% 98.1% 98.1%

≥ 90% ↓

51 51

52 52

13

46.2%

109

122

89.3%

8

251

3.2%

46

7. Proportion of acute stroke clients discharged to inpatient rehabilitation

# of ischemic and hemorrhagic stroke clients admitted to inpatient rehabilitation following discharge from acute services for a stroke. 42

54.5%

50% ↑

12 18

20 33

Median length of stay in acute care (days)

Rate 1.8% 2.5% 2.9%

Stroke Distinction Dashboard 6 Month Roll Up (January to June 2015)

March 2015 June 2015 Sept 2015

Indicators Protocols Standards Education Innovation

Acute

target 7/9

Rehab

target 3/4

Acute

target 9/14

Rehab

target 4/6

Acute

target 75%

Acute

High Priority

target 90%

Rehab

target 75%

Rehab

High Priority

target 90%

Client & Staff Protocols

target 4/4

Documentation Protocols

target 2/4

Research Project

Rating Rating Rating Rating Rating Rating Rating Rating Rating Rating Rating

7 of 9 4 of 4 11 of 14 5 of 6 79% 80% 82% 2 of 4 2 of 4

Stroke/TIA mortality % Clients treated on ISU

EMS Stroke Screening Formal intake criteria

79% Green

80/101

80% Green

20/25

82% Green

70/85

95% Green

18/19

Material available Standard tool SPC Process Improvement

% Ischemic stroke receiving tPA

LOS in rehab following an acute stroke

EMS Bypass Swallowing ability assessment

19% Yellow

19/101

20% Yellow

5/25

18% Yellow

15/85

5% Yellow

1/19

Variety of languages

Documentation location

Median tPA door-to-needle time

% clients on antithrombotic at

discharge

EMS pre-notification Initial assessment of rehab needs

2% Red

2/101

0% Red

0/25

0% Red

0/85

0% Red

0/19

Format for special needs

Documentation by HCP

% Clients treated on ISU

% clients with dysphagia screen

ED notify Stroke Team Falls prevention Clients report receiving education

Specific content

LOS in Acute care CT for potential stroke pts

Assess/manage diabetes

Readmission rate tPA eligibility screening Pressure ulcer prevention

% clients discharged to rehab

tPA administration

% clients on antithrombotic at

discharge

Pressure ulcer prevention

% clients with initial dysphagia screen

Assessment of rehab needs

Formal criteria for rehab referral

Falls prevention

Admins acute ASA therapy

Assess/manage diabetes

Swallowing assessment

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Acute Standards Overview

Standard Evidence of Lakeridge Health Compliance

Investing in Comprehensive Acute Stroke Services

1.0 The site collects and analyzes information about the need for acute stroke services

1.1 The site annually collects information about stroke occurrence in the population it serves.

Lakeridge Health Programs Score Card:

Post-Acute Specialty Services https://lh-web-app/scorecard/Scorecard.aspx?ScorecardID=25

Emergency Department https://lh-web-app/scorecard/Scorecard.aspx?ScorecardID=6

Critical Care https://lh-web-app/scorecard/Scorecard.aspx?ScorecardID=5

Stroke Prevention Clinic Performance Indicators (wait times, referrals, visits, patient satisfaction, priority status, referral source)

Decision Support, District Stroke Coordinator & Quality Coordinator report data at Post-Acute Specialty Services Council & Quality Committee and Emergency & Critical Care Quality Council

Stroke Distinction Metrics Scorecard reported monthly to the Stroke Distinction Sub-Committee by Metrics Working Group

Durham District Stroke Centre Reporting to the Durham District Stroke Council

Participation in 2009/10 - 11/12 Ontario Stroke Audit Participation in 2011-12 Stroke Prevention Clinic Audit

Participation in Ontario Stroke Network Stroke Report Card analysis and interpretation for Central East LHIN http://thewave.corp.lakeridgehealth.on.ca/news/Pages/High-

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Marks-for-Stroke-Care-at-Lakeridge-Health.aspx

Provincial Telestroke Metrics monitored

Quarterly and Fiscal Year Hyperacute Statistics Memo sent to Senior Leadership Team in Emergency Department and Critical Care for posting on Continuous Quality Boards and communication with staff

Participation in Canadian Institute for Health Information (CIHI) Project 340 and Special Project 740

1.2 When planning stroke services the site collects

information about the prevalence of major risk

factors for stroke in the population it serves.

Data from Statistics Canada and Central East LHIN utilized to review and guide Lakeridge Health Stroke Services

Heart and Stroke Foundation Reports on Canadian Stroke Health

Heart Association Stroke Journal

1.3 The site collects demographic information

about high- risk and hard-to-reach

populations.

Alignment of Lakeridge Health with Central East Stroke Network (CESN) and Ontario Stroke Network (OSN) work plans

Durham District Stroke Council as representation from, Self-Management, Heart and Stroke Foundation, COPE Mental Health, March of Dimes, Stroke Survivor, Emergency Department, Emergency Medical Services, Brain Injury Association and Durham Diabetes Network, Oshawa Seniors Citizens Centre and Durham Diabetes Network

Durham District Stroke Coordinator member of Central East Acquired Brain Injury Network

1.4 The site uses information about urban & rural

populations to analyze geographical barriers to

stroke services.

Durham District Stroke Coordinator member of Central East LHIN Stroke Working Group for stroke system redesign

Central East Stroke Network Work Plan 2014-2015

3


Lakeridge Health Daily Stroke Admissions report for all sites

Emergency Department Tracker in Meditech


Engaging a Prepared and Proactive Acute Care Services Team

2.0 The stroke team uses an Interprofessional approach to coordinate and deliver hyperacute and acute stroke services:

2.1 The team has adopted and implemented the

Canadian Best Practice Recommendations for

Stroke Care for the assessment and

management of stroke clients.

Ischemic Stroke – Alteplase Pre Printed Order Set, Ischemic Stroke – Non-Alteplase/Post Alteplase (Greater than 24 hours) Admission Orders Pre Printed Order Set and Interprofessional Clinical Pathway for Ischemic Stroke (5 Acute Days) are developed and revised based on the Canadian Best Practice Recommendations

Continuing education sessions provided to all Lakeridge Health staff (Provincial Stroke Rounds, Central East Stroke Network Rounds, National Stroke Rounds, Stroke Education Day)

Ongoing participation in research (Stroke Prevention Clinic & Integrated Stroke Unit)

Code Stroke Box in Emergency Department and Critical Care

Paramedic Prompt Card

Implementation of standardized stroke assessments and documentation for depression, swallowing, sleep apnea, cognition and function on the Integrated Stroke Unit and in the Stroke Prevention Clinic

4


2.2 The team consists of physicians, nurses, PTs,

OTs, SLPs, social workers, dieticians, and

pharmacists with expertise in stroke care.

Integrated Stroke Unit Interprofessional team includes Physicians (Hospitalist, Physiatrists and Neurologists), Nursing (RN and RPN) Patient Care Specialist, OT, PT, SLP, Rehabilitation Assistants, Social Work, Pharmacist, Clinical Nurse Specialist. Registered Dietitian Neuropsychologist, Community Care Access Centre Worker, Ethicist & Chaplain available on consultation

Interprofessional Team Video https://www.youtube.com/playlist?list=PL2jY9UzvBjU2Gy9k-ul9bPO6lWGwbft2Y

2.3 The team has clearly defined roles &

responsibilities for delivering stroke services to

client, family & caregiver.

Team roles and responsibilities outlined in the Interprofessional Clinical Pathway for Ischemic Stroke (5 Acute Days)

A video of meet the stroke team has been created to help clarify the roles of the team members to patients and families https://www.youtube.com/playlist?list=PL2jY9UzvBjU2Gy9k-ul9bPO6lWGwbft2Y

2.4 Each team member has the necessary

credentials or license from the appropriate

college or association.

Human Resources receive information on Nurse & Interprofessional Practice for allied health care members for members not in good standing. Information reported to employee manager

Credentials are checked annually and maintained by Human Resources

New hires have vulnerable sector check completed

2.5 The team orients new staff & service providers

about the unique aspects of acute stroke All new Lakeridge Health Staff receives Interprofessional

orientation to the stroke services at Lakeridge health

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services.

ISU Specific Orientation (ISU Orientation Process Map)

Code Stroke/Critical Care Clinical Assistance Orientation Package

All new staff must attend a stroke workshop either at Lakeridge Health or at Peterborough Regional Health Care Centre

All new staff of the Integrated Stroke Unit are asked to review stroke materials prior to working on the unit

2.6 The team receives ongoing professional

development & training to deliver current

evidence based hyperacute & acute stroke

services.

Continuing education sessions provided to all Lakeridge Health staff (Provincial Stroke Rounds, Central East Stroke Network Rounds, National Stroke Rounds, Grand Rounds, Stroke Education Day)

Centralized education sessions for TOR-BSST©, Canadian Neurological Scale and Post Stroke Depression

Unit Huddles

Signs of Stroke and In-House Code Stroke procedure included in Lakeridge Health Passport to Safety and uLearn (Lakeridge Health Learning Management System) Module

In-House Code Stroke Mocks and Debriefs

Mock Tracers utilizing Lakeridge Health Tracer Team

Access to on-line refresher for TOR-BSST© posted on uLearn (Lakeridge Health Learning Management System) for all certified assessors to access

Central East Stroke Network Education Funds utilized to support ongoing education (sponsored 2 ISU staff members to attend the 2015 Canadian Stroke Congress)

Toronto Stroke Networks Virtual Community of Practice promoted to staff as a tool for ongoing education http://www.strokecommunity.ca/

6


Staff encouraged to complete Apex Innovations, Canadian Hemispheres online stroke training and funding for licenses is provided by the Central East Stroke Network and facilitated by the District Stroke Centre https://www.apexinnovations.com/CanadianHemispheres.php

Staff encouraged to complete the online acute stroke management modules through the Southwestern Ontario Stroke Network http://swostroke.ca/acute-stroke-unit-orientation/

Staff encouraged to certify for the National Institutes of Health Stroke Scale through the American Heart Association

2.7 The team uses information from performance

evaluations to improve acute stroke services, &

identify support, training, or development of

team needs.

Performance appraisals completed every 2 years or sooner if need arises using Lakeridge Health standardized tool as per outlined in the Performance Assessment and Development Policy and Procedure


3.0 The Interprofessional team providing acute stroke services has support from leadership and resources to provide effective services:

3.1 The interdisciplinary team providing acute

stroke services has a designated coordinator.

Integrated Stroke Unit Patient Care Manager (Mary McAvoy)

Integrated Stroke Unit Patient Care Specialist (Angela Buffet)

Emergency Department Patient Care Manager (Mary Derks)

Emergency Department Patient Care Specialist (To be determined)

Critical Care Patient Care Manager (Susan Ord)

Critical Care Patient Care Specialist (Sherry Campbell)

7


Stroke Physician Lead (Dr. Leo Chiu)

District Stroke Coordinator (Amy Maebrae-Waller)

District Stroke Centre Clinical Nurse Specialist (Anna Sewell)

Chief of Neurology (Dr. David Crisp)

Medical Director, Critical Care (Dr. Randy Wax)

Medical Director, Post Acute Speciality Services (Dr. Luigi Pedretti)

3.2 The team works with staff, other service

providers and community partners to develop

goals and objectives for acute stroke services

that align with the site’s strategic & operational

plans.

Lakeridge Health Organizational Charts

Durham District Stroke Council

EMS Stroke Education Sessions (September 2015)

Post Acute Specialty Services Council & Quality Committee

Emergency & Critical Care Quality Council

Ontario Stroke Network Organizational Chart

Central East Stroke Network Organizational Chart

3.3 The team has resources to establish & support

dedicated stroke units for acute stroke services. 28 bed (5 acute and 23 rehabilitation) Integrated Stroke Unit

located on OC5

Dedicated Interprofessional team

3.4 The layout of the physical space contributes to

the effectiveness & safety of stroke services. Shared treatment space located on 5A includes; conference

room, 3 Interprofessional treatment spaces, assessment space, patient dining room, activities of daily living kitchen and bathroom

Wide hallways, wheelchair accessible showers and bathrooms, wander guard in place, tab alarms

3.5 When delivering acute stroke services, the team

has access to equipment & supplies appropriate Dedicated budget for Integrated Stroke Unit

Integrated Stroke Unit has access to the Lakeridge Health

8


to the needs of the stroke clients & the

population it serves.

Central Equipment Management (wheelchairs, lifts and transfer devices, bariatric equipment, V.A.C. Therapy devices, specialty surfaces and beds)

Annual review of Capital Equipment needs

Lakeridge Health Foundation provides occasional support from donated funds

3.6 The team uses Telehealth to increase access to

stroke specialists. Telestroke used in Emergency Department and Critical Care to

assist with tPA delivery

Ontario Telehealth Network used in Stroke Prevention Clinic for consultations

Criticall used for access to vascular and neurosurgery consults


4.0 The stroke team collaborates with other service providers, and organizations to coordinate timely access to acute stroke services for stroke clients in the community:

4.1 The team establishes internal partnerships with

the emergency department, neurology, critical

care, internal medicine, diagnostic labs, and

neurovascular surgery & imaging departments

to coordinate & organize access to services.

District Stroke Coordinator attends Quality Committee and Emergency & Critical Care Quality Council

District Stroke Centre Clinical Nurse Specialist attend the Nursing Professional Practice Sub-Committee

Stroke Distinction Sub-Committee has membership from Emergency Department, Critical Care, Integrated Stroke Unit, Diagnostic Imaging and Quality, Improvement and Risk Management

Memorandum of Understanding for Medical Direct and Repatriation of Acute Stroke Patients within Durham Region with Uxbridge Cottage Hospital and Rouge Valley Health Systems –

9


Ajax

Lakeridge Health internet “Stroke Care” Resource Centre

Lakeridge Health intranet (WAVE) has Integrated Stroke Unit, and District Stroke Centre & Stroke Prevention Clinic pages

Criticall utilized for neurology, neurosurgery and vascular consultations as required

4.2 The team identifies partnerships and

collaborates with other service providers and

organizations including surrounding acute care

organizations, EMS to coordinate and plan

acute stroke services within the sites

boundaries and to provide access to

appropriate stroke services for clients.

Memorandum of Understanding for Medical Direct and Repatriation of Acute Stroke Patients within Durham Region

Acute Stroke (Within Durham Region) - Policy and Procedures for the Redirection and Repatriation of Stroke Patients within Durham Region

Cross continuum and cross organization representation on Durham District Stroke Council

Annual Stroke Awareness Month Campaign hosted by District Stroke Centre and the Durham District Stroke Council

Partnership with March of Dimes Stroke Recovery Canada to host Living with Stroke community education sessions


4.3 The team has a strategy to raise awareness in

the community about the signs and symptoms

of stroke and about the appropriate actions to

take in the event of possible stroke to access

acute stroke services.

Durham District Community Outreach Activities (2014-2015) and Community Let’s Talk about Stroke, Do You Know the Signs? education sessions

Ontario Stroke Network Stroke Month Communication Plan (2015)

Heart and Stroke FAST Screensavers at Lakeridge Health

Heart and Stroke FAST on all Lakeridge Health lobby televisions

Heart and Stroke FAST and Durham District Poster sent to

10


external partners and community providers

Lakeridge Health “Stroke Care” Resource Bookmark

CE LHIN Healthline Stroke Resource microsite

Lakeridge Health Intranet Articles

Lakeridge Health Social Media tools

Heart and Stroke FAST Elevator skins on Integrated Stroke Unit elevator doors


Providing safe and appropriate Hyper-Acute and acute stroke services

5.0 The stroke team coordinates stroke services with EMS and the ED:

5.1 The team contributes to ongoing education for

EMS about assessment & management of

suspected stroke clients at the pick-up & during

transport.

EMS Management of Acute Stroke Patients include in 2015 EMS education sessions in September of 2015

Paramedic Prompt Card for Acute Stroke Protocol

Ongoing planning and communication with Region of Durham Paramedic Services, Quality and Development Facilitator for process improvement activities

tPA Process Improvement Memos sent to Lakeridge Health Clinical Manager, Paramedic Programs

11


5.2 The team has protocols & MOU’s with EMS for

direct transport to stroke centres, bypass of

smaller centres, use of air ambulance &

screening tools for suspected stroke clients.



CT Downtime - Stroke Alteplase Policy and Procedures

5.3 The team has protocols with EMS to receive

pre-notification of suspected acute stroke clients

in transit.


CT Downtime - Stroke Alteplase Policy and Procedures

Downtime Procedure – CT or MRI

5.4 EMS, ED’s & stroke teams use agreed upon

triage levels to assign clients with suspected

stroke and use these while communicating.



Paramedic Prompt Card for Acute Stroke Protocol

5.5 The ED & stroke team initiate stroke protocols

when pre-notification received from EMS so

stroke clients are received efficiently from EMS

personnel when they arrive.


Ambulance Call Report

5.6 A designated stroke team member is notified

when a suspected stroke client is in transit, or

as soon as the client arrives at the ED.


12


5.7 The stroke team responds to ED requests for

evaluation of a suspected stroke client to

optimize opportunities for time-sensitive

interventions.

Acute Stroke (Within Durham Region) – Policy and Procedure for the Redirection and Repatriation of Stroke Patients within Durham Region

Ischemic Stroke – Alteplase Pre Printed Order Set

Ischemic Stroke – Non-Alteplase/Post Alteplase (Greater than 24 hours) Admission Orders Pre Printed Order Set

Physician Initial Assessment benchmark of 10 minutes included in Acute Stroke Protocol Memo

5.8 The stroke team consults with other stroke

facilities to rapidly & efficiently transfer stroke

clients to or from another ED or acute inpatient

setting to meet the emergent needs of stroke

clients.


Lakeridge Health Physician Report for Stroke/TIA Repatriation Patients utilized as a communication for patients who are repatriated to other facilities following the Acute Stroke Protocol bypass



6.0 The stroke team provides immediate hyper-acute management for stroke clients:

6.1 The ED triage staff or stroke team conducts on

each client with suspected stroke immediately

upon arrival at the ED, regardless of how the

client arrives.

Stroke Signs - Cincinnati Stroke Scale utilized in Emergency Departments

Process for walk-in patients outlined in the Acute Stroke (Within Durham Region) – Policy and Procedure for the Redirection and Repatriation of Stroke Patients within Durham Region

Heart and Stroke FAST Screen Savers on all Lakeridge Health computers

13


6.2 The stroke team and ED personnel have

protocols for rapid assessment & management

of clients with signs or symptoms suggestive of

stroke or TIA.




CT Head STAT for Alteplase Order

Code Stroke Box (Emergency Department and Critical Care) contains all necessary documents a Code Stroke

Non admitted TIA patients can be referred to the Lakeridge Health Stroke Prevention Clinic for triage based on the Ontario Stroke Network Ambulatory Care Triage Algorithm for Patients with Suspected or Confirmed Transient Ischemic Attack or Stroke

6.3 The stroke team gathers information about VS,

neuro status, time of onset, deficits (e.g.

cognitive, functional) & medications.

Ischemic Stroke – Alteplase Pre Printed Order Set and Ischemic Stroke – Non-Alteplase/Post Alteplase (Greater than 24 hours) Admission Orders Pre Printed Order Set utilized to guide assessment

TOR-BSST©, Canadian Neurological Scale, National Institute of Health Stroke Scale

Last Seen Normal and triage assessment data entered into Meditech electronic record on Emergency Room NACRS Initiative screen by triage nurse

Pharmacist complete a medication review during Code Stroke

6.4 The stroke team or ED personnel follow

established protocols for clients with suspected

acute stroke to undergo brain imaging


14


immediately upon arrival to hospital. Ischemic Stroke – Alteplase Pre Printed Order Set


CT Head STAT for Alteplase Order

6.5 The acute stroke team or ED staff checks the

client’s blood glucose as part of initial blood

work & repeats if initial values abnormal.




STAT bloodwork entered via Meditech using Alteplase HDALT order set for bundled bloodwork

6.6 The acute stroke team or ED staff assesses

stroke clients to determine their eligibility for t-

PA using current criteria in the Canadian Stroke

Strategy’s Canadian Best Practice

Recommendations for Stroke Care.

tPA Inclusion/Exclusion criteria include in Phase 1 of the Ischemic Stroke – Alteplase Pre Printed Order Set and completed by the Emergency Department Physician

National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT scores are utilized to inform management during Code Strokes

6.7 The acute stroke team and/or ED staff

coordinate administration of tPA to ensure it’s

initiated within 1 hour of hospital arrival &

monitors their administration times.



CT Head Alteplase alerts sent in real time to District Stroke Coordinator, District Stroke Clinical Nurse Specialist and Integrated Stroke Unit Managers

Audit Tool for Acute Stroke Protocol completed for all

15


administrations

Acute Stroke Protocol Memo completed for all administrations

District Stroke Centre Clinical Nurse Specialist supports Code Strokes when onsite

6.8 The acute stroke team or ED staff administers

tPA in accordance with the current Canadian

Best Practice guidelines for tPA with respect to

mode of administration, dosage and infusion

time.



Lakeridge Health tPA audit tool

Lakeridge Health Decision Support tPA Administration Report

Lakeridge Health Pharmacy tPA Administration Audit run biweekly and sent to District Stroke Coordinator

Telestroke

Lakeridge Health participates in CIHI 340 mandatory reporting. A “Data Sources Manual for CIHI 340 & Special Project 740: A District Stroke Centre Initiative to Support Accuracy of Stroke Performance Measures Data” was created in 2013 (and updated in 2014 and 2015) to assist coders with data coding

6.9 The acute stroke team screens & documents

client’s swallowing using a simple, valid &

reliable bedside testing protocol prior to

initiating PO intake of meds, fluids or food.



TOR-BSST© used for dysphagia screening (Emergency Department uses paper tool, Critical Care/Integrated Stroke Unit)

Swallowing Precaution Poster utilized on Integrated Stroke Unit

Dysphagia Policy and Procedure for Suspected and/or Acute Stroke

Dysphagia Screener List posted on intranet if no certified

16


screener is available http://thewave.corp.lakeridgehealth.on.ca/programs/pass/ddscaspc/Pages/Dysphagia-Screeners-List.aspx

6.10 The team refers clients with features of

dysphagia or pulmonary aspiration for a full

clinical assessment of their swallowing ability

by a SLP or appropriately trained specialist to

advise on swallowing ability & consistency of

diet & fluids.

TOR-BSST© used for dysphagia screening, failure triggers automatic referral to SLP and Dietitian

Integrated Stroke Unit participating in “Clinician Evaluation of the Swaltek* Air Pulse Therapy Device in Subjects with Swallowing lmpairment Secondary to Cerebral Vascular Accident” research study

Modified Barium Swallowing Tests can be completed in collaboration with Lakeridge Health Diagnostic Imaging Department

6.11 The acute stroke team administers at least 160

mg of ASA to all acute adult stroke clients after

brain imaging has ruled out ICH.



6.12 The acute stroke team has rapid access to

neurosurgery & vascular surgery services to

collaborate on assessment & management of

clients with hemorrhagic stroke, intracerebral

stroke or other appropriate clinical indicators.

Criticall



6.13 The acute stroke team orders carotid imaging

tests for clients with carotid territory TIA or

ischemic stroke & follows up on results, even if

the client is discharged directly from the ED.



Carotid Dopplers completed

CTA available upon request

17


6.14 The stroke team refers clients discharged

directly from ED with a diagnosis of TIA or

minor stroke to a stroke prevention clinic or

physician with specific stroke expertise for

further assessment & management.

Stroke Prevention Clinic Referral

Automatic Stroke Prevention Clinic Referral from Lakeridge Health Emergency Departments with email alert to Stroke Prevention Clinic

Stroke Prevention Clinic patient information sheet prints with automated referral in the Emergency Department

Monthly Stroke Prevention Statistics Report provides details on referral date, referral source and referral reason

6.15 The team provides clients with written

discharge information at the time of transition

that includes action plans, follow-up care &

appointments, & identifies client recovery

goals.

Education package provided to patients on discharge from Emergency Department, Integrated Stroke Unit and Stroke Prevention Clinic

Lakeridge Health Discharge Instruction Record reviewed and copy provided to patient prior to discharge

Decision Support Meeting Tool reviewed and copy provided to patient

Patient goals and self-efficacy are included in the patient education classes.

Your Stroke Journey provided in education package and patients/families encouraged to record personalized information

Integrated Stroke Unit Patient and Family Education class presentations and video series available on unit and on external website for all Durham Region residents to access

Personal Exercise Program – Sample Exercises provided by Interprofessional team

6.16 The team effectively transfers information to

inpatient stroke services about VS, time of

onset, lab results, neurological signs &


Unit to Unit Transfer of Accountability

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fluctuations in status, diagnostic information

(complete or in process), medications given in

ED & interventions (e.g. t-PA) and family

member accompanying the client.


7.0 The stroke team provides comprehensive inpatient acute stroke services:

7.1 Clients admitted for an acute stroke or TIA are

managed on a dedicated acute stroke unit. Integrated Stroke Unit located on OC5 (5 acute beds, 23 rehab

beds)

If no bed available on OC5 TIA patients may be admitted to G8 Short Stay Unit

7.2 When clients are not managed on a dedicated

stroke unit there is a process for clustering

patients.

Not applicable

7.3 The stroke team has a process to identify and

list all stroke clients daily, including those on the

stroke unit, new in-house admissions since

previous rounds, & strokes that occur in clients

already admitted within the organization for

other initial health condition.

Lakeridge Health Daily Stroke Admissions report for all sites automatically prints daily at 6am to District Stroke Coordinator, District Stroke Clinical Nurse Specialist and Integrated Stroke Unit Mangers

Lakeridge Health Bed Status Alert

7.4 The stroke team conducts a daily review of

stroke clients to identify & update their case

needs.

Rapid Round completed on Integrated Stroke Unit three times per week

Critical Care completes rapid rounds daily

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7.5 The stroke team assesses the client’s stroke

rehab needs within the first 48 hours after

admission.

Interprofessional Clinical Pathway for Ischemic Stroke (5 Acute Days)


Lakeridge Health Stroke Triage Model

7.6 The stroke team continues to monitor clients’

blood glucose as indicated by client status. Ischemic Stroke – Non-Alteplase/Post Alteplase (Greater than

24 hours) Admission Orders Pre Printed Order Set


7.7 The team assesses stroke clients for their risk

of developing venous thrombo-embolism, &

implements appropriate management

strategies.



Lakeridge Health VTE Patient Education materials

7.8 The stroke team monitors client temperatures

as part of routine vital signs & implements

appropriate measures for increased

temperatures.



7.9 The team mobilizes stroke clients as early and

as frequently as possible and within 24 hours of

stroke symptom onset unless contraindicated.



Lakeridge Health Mobility Standard of Care (Adults) and Mobility Algorithm

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Mobility and functional status is recorded on patient communication boards at bedside

7.10 The team assesses stroke clients for urinary

incontinence and retention, with or without

overflow, fecal incontinence, and constipation

and implements appropriate management

strategies for these conditions.


Interprofessional Clinical Pathway for Ischemic Stroke (5 Acute Days) Lakeridge Health Urinary Catheter Protocol and Prevention of Catheter Associated Urinary Tract Infection materials

Integrated Stroke Unit utilizes Prompted Voiding Tools, Voiding Records and Voiding/Fluid Records

7.11 The team assesses hydration status upon

admission & implements appropriate

intervention strategies to maintain adequate

hydration for stroke clients.



7.12 The team screens for the nutritional status of

stroke clients upon admission using a valid

screening tool, and implements appropriate

management strategies for clients with

nutrition deficits.

Malnutrition Screening Tool (MST) included in Ischemic Stroke – Non-Alteplase/Post Alteplase (Greater than 24 hours) Admission Orders Pre Printed Order Set.

Failure of Malnutrition Screening Tool automatically triggers a referral to Dietitian

7.13 The team implements and evaluates a falls

prevention strategy specific to stroke clients to

minimize the risk of falls in this population.

Lakeridge Health Falls Prevention and Management for Adult Patients (older than 18 years) Policy and Procedures

Morse Falls Scale completed by nursing

Physiotherapist complete BERG Balance Scale on admission to Integrated Stroke Unit

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Lakeridge Health patient education materials handout on Patient Safety – Your Role

7.14 The team assesses each client’s risk for

developing a pressure ulcer & implements

interventions to prevent pressure ulcer

development.

Braden Scale completed by nursing

Access to specialized surfaces through Lakeridge Health Central Equipment Management

Preventing Pressure Ulcers staff materials


Consultation available with Nurse Practitioner with specialization in wound prevention, assessment, management, treatment

Post Acute Speciality Program monitors incidence of ulcers in Complex Continuing Care and reports rates on Program Scorecard https://lh-web-app/scorecard/Scorecard.aspx?ScorecardID=25

Monitoring proportion of inpatients with stroke that experience pressure ulcers as a complication during inpatient stay as optional Stroke Distinction Metric

7.15 The team screens clients with stroke for

changes in cognition during inpatient stay, at

all transition points, and whenever clinical

presentation indicates.


Occupational Therapist complete Montreal Cognitive Assessment (MOCA) and or Mini Mental Status Examination (MMSE)

Completion of cognitive screening is tracked on “Stroke View” in Meditech patient record

Meditech report available to monitor completion rates of cognitive screening

Screening rates and monthly goals are posted on Integrated

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Stroke Unit Continuous Quality Improvement Board

7.16 The team refers clients with cognitive changes

or suspected cognitive changes during

screening to a health care professional with

expertise in cognition for further assessment,

diagnosis & development of a treatment plan.

Occupational therapists develop treatment plan for patients and interprofessional team

Consultations with Physiatrist, Geriatrician and Neuropsychologist available

7.17 The team screens clients with stroke for

depression using a validated tool during

inpatient stay, at all transition points &

whenever clinical presentation indicates.


Integrated Stroke Unit uses SADQ-H10 or PHQ-9 to screen for depression



Screening rates and monthly goals are posted on Integrated Stroke Unit Continuous Quality Improvement Board

Screening for Post Stroke Depression at all Points in Care: A Lakeridge Health Initiative poster presented at 2013 Stroke Collaborative

Post Stroke Depression education included in Interprofessional Education Calendar

7.18 The team refers clients identified as at risk for

depression during screening to a health care

professional with expertise in mental health for

further assessment, diagnosis, & development

of a treatment plan.

Positive findings on PHQ-9 or SADQ-H10 will prompt a referral for psychiatrist, psychologist, or social worker referral

Upon discharge from inpatients follow up at Lakeridge Health Ambulatory Rehabilitation Centre Physiatrists Clinics can be utilized

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Helping Clients and Families Live with Stroke

8.0 The stroke team provides timely and comprehensive education and support to stroke clients, their families and caregivers:

8.1 The team has identified which team members

are responsible for providing education &

materials to clients, families & caregivers.


Patient/Family Stroke Education classes conducted by Interprofessional team on a weekly basis

Your Stroke Journey provided in education package on admission to ISU

Integrated Stroke Unit Patient and Family educational video series

Integrated Stroke Unit Patient Care Specialist coordinates stroke education sessions and guest speakers

8.2 The team provides education & education

materials to clients, families & caregivers about

living with stroke & identifying & addressing

potential changes in role and lifestyle.



Community Resources and Self-Management Information included in educational packages in Emergency Department, Integrated Stroke Unit and Stroke Prevention Clinic

March of Dimes Stroke Recovery Canada, Community Care Durham and Lifeline host presentations and visit Integrated Stroke Unit

Peers Fostering Hope Visits on Integrated Stroke Unit

Information on upcoming Living with Stroke Sessions provided and posted on Integrated Stroke Unit

Educational information and resources available on resource

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board display on Integrated Stroke Unit

Durham District Community Resource Guide for Individuals Living with Stroke and their Caregivers available on Integrated Stroke Unit and “Stroke Resources” section of www.lakeridgehealth.on.ca

8.3 The team provides education that promotes

self-efficacy through mastering self-

management skills.

Goal setting discussed in group education classes and on an individual basis

Individualized patient goals are posted in patients room on communication board

Community Reintegration opportunities discussed in education classes

Information about Community Resources, smoking cessation and self-management classes are provided in education package


8.4 The team provides training to family &

caregivers to safely care for clients after

discharge.

Tips and Tools for Everyday Living: A Guide for Stroke Caregivers is available on the Integrated Stroke Unit

Family and Team Case Decision Support Meetings

Overnight passes with family prior to discharge

Medication teaching and management counselling

Group Education Classes for patients and families

Individualized training with staff to address specific needs ( e.g. transfers/mobility, safe feeding, supportive communication and ostomy care)

If required the Community Care Access Centre or the Integrated Stroke Unit Interprofessional team can complete

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home visit prior to discharge

8.5 The education & resources provided by the

team are appropriate to the client’s phase of

care or recovery & client, family, & caregiver

readiness and needs.

Multilingual materials available on the Integrated Stroke Unit and Stroke Prevention Clinic

Patients and families have access to “aphasia friendly” education materials in different learning modalities (group classes, one to one sessions, independent learning and in video format)

Several allied Health team members are trained in Supportive Conversation for Adults with Aphasia and Supportive Conversation kits are available in SLP office

Translation service available if required

Lakeridge Health Integrated Stroke Unit participated as a recruitment site in the Optimizing Stroke Family Caregiver Support across the Care Continuum by Improving the Timing of Intervention research study (2011 to 2012)

8.6 The team formally documents client received

education prior to discharge. Education provided to patients/families by nursing is

documented Meditech under Education/Psychosocial screens

Education provided to patients/families by allied health team members is documented Meditech under OT: Individual Therapy, PT: Treatment and SLP under patient care notes

8.7 The team provides emotional support &

counseling to clients, families, & caregivers to

help them adjust and cope with the effects of

stroke.

Education and referrals to community supports provided prior to discharge

Counselling and support provided by Interprofessional team members, including Social Work

Access to Spiritual Care services

Peer Fostering Hope, Community Care Durham and March of

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Dimes Stroke Recovery Canada providers visit Integrated Stroke Unit

Information on local Stroke Support Groups posted on Integrated Stroke Unit, Stroke Prevention Clinic and on www.lakeridgehealth.on.ca Stroke Resources page


9.0 The stroke team provides initiates secondary prevention strategies for acute care clients to help prevent recurrence of stroke:

9.1 The team refers clients who have experienced a

minor stroke or TIA to stroke prevention clinics

or MD’s with stroke expertise for ongoing

assessment and secondary stroke prevention.

Referral to Stroke Prevention Clinic included Ischemic Stroke – Alteplase Pre Printed Order Set and Ischemic Stroke – Non-Alteplase/Post Alteplase (Greater than 24 hours) Admission Orders Pre Printed Order Set

TIA patients can be referred to the Lakeridge Health Stroke Prevention Clinic for triage based on the Ontario Stroke Network Ambulatory Care Triage Algorithm for Patients with Suspected or Confirmed Transient Ischemic Attack or Stroke

Electronic referral available for Emergency Department and Integrated Stroke Unit

Stroke Prevention Clinic Brochure included in Emergency Department Education packages

Stroke Education Video Series – Stroke Risk Factor Video

Stroke Prevention Clinic staffed by a registered nurse and physicians (General Internal Medicine and Neurologist)

9.2 The team provides clients, family & caregivers

given information on lifestyle modifications to

address vascular risk factors for recurrent

Education materials included in Integrated Stroke Unit Education Package and reviewed during Stroke Education classes


Individualized teaching to patients and family as required

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stroke.

9.3 The acute stroke team assesses clients for the

presence of HTN & appropriately manages

elevated BP in clients with stroke.



Stroke Education Video series includes education on blood pressure

Educational materials available on the resource display board on Integrated Stroke Unit and in the Stroke Prevention Clinic

9.4 The team assesses clients for the presence of

elevated lipid levels & appropriately manages

elevated lipid levels.



Stroke Education Video series includes education on cholesterol

Educational materials available on display board on Integrated Stroke Unit and in the Stroke Prevention Clinic

9.5 The team has established protocols to assess &

manage diabetes in clients admitted following a

stroke.



Hypoglycaemia Protocol (Adults – 16 years and over)

Pre Printed Order Insulin for EATING patients with Diabetes

Pre Printed Order Insulin for NOT EATING patients with Diabetes

Referral to Central East Community Care Access Centre Diabetes Centre completed upon discharge if required

9.6 The team prescribes adult clients with ischemic

stroke or TIA with antiplatelet therapy for Ischemic Stroke – Alteplase Pre Printed Order Set

Ischemic Stroke – Non-Alteplase/Post Alteplase (Greater than 24

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secondary prevention of recurrent stroke unless

there are contraindications, or an indication for

anticoagulation.

hours) Admission Orders Pre Printed Order Set

Core Metric monitored on Stroke Distinction Performance Score Card

Patient and family education sheets available in the Stroke Prevention Clinic

9.7 The team treats adults with stroke & Afib with

anticoagulants unless contraindicated. Ischemic Stroke – Alteplase Pre Printed Order Set


9.8 The team addresses anticoagulation

compliance with the anticoagulation regimen

with stroke clients, families, & caregivers in their

follow up with clients.

Patients/caregivers are provided with the Your Stroke Journey book in the Integrated Stroke Unit education package

Stroke Education Video series includes education on anticoagulants and antiplatelet

Pharmacist on Integrated Stroke Unit available for consultation and individualized teaching for patients and family

9.9 The acute stroke team collaborates with

neurosurgery & vascular surgical services to

refer & follow up clients with carotid stenosis

who are candidates for possible surgical

intervention.

Criticall utilized for consultation

Stroke Prevention Clinic organizes consultation with the Vascular Surgery Office in Peterborough

9.10 The acute stroke team has a process to assess

& determine smoking status & provide

information on smoking cessation.

Smoking status assessed on admission to Integrated Stroke Unit

Nicotine replacement offered to patients

Smoking Cessation resources from the Canadian Cancer society and The Lung Association available on Integrated Stroke Unit and in the Stroke Prevention Clinic (available in multiple languages)

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10.0 The stroke team prepares clients and their families for discharge or transfer:

10.1 The team initiates discharge planning from

time of admission. Discharge Support Meeting with patient/family member and

members of Interprofessional team held two weeks prior to discharge (or sooner if required)

Interprofessional team rounds held every Tuesday and Thursday at 11:00 barriers to discharge, support services and referrals to be completed prior to discharge are discussed and recorded on rounds board in order to make information available for all team members

10.2 Uses formal criteria to identify stroke clients

ready for In-patient rehabilitation & makes a

referral for inpatient services.


Interprofessional Clinical Pathway for Stroke Inpatient Rehabilitation (5 weeks)

Lakeridge Health Stroke Triage Model base on standardized tools including Alpha FIM ® assessment completed on Day 3

10.3 The team develops a transition & follow up

plan with input from client, family & caregiver

that includes information about ongoing

recovery, signs and symptoms of declining

health status, referrals for follow up services,

individually prescribed exercise program &

contact information for follow up with the team.

Discharge Support Meeting Decision held with patient/family

Emergency Department and Integrated Stroke Unit Education packages include information on signs of stroke and stroke recovery (Your Stroke Journey)

Stroke Education classes review signs of stroke and recovery following a stroke

Integrated Stroke Unit patients provided with Stroke Navigation Telephone Number (included on Decision Support Meeting Tool)

Referrals sent to at Ambulatory Rehabilitation Centre (ARC), Community Care Access Centre or Together in Movement and Exercise Programs for outpatient rehabilitation and exercise

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services

10.4 The team helps clients, families & caregivers

access stroke self- management programs. Information on Central East Community Care Access Centre

Self-Management Program included in Emergency Department, Integrated Stroke Unit and Stroke Prevention Education Packages

10.5 The team has a written list of community

services & helps clients, families & caregivers

access these upon discharge.

List of Community Resources included in education packages in Emergency Department, Integrated Stroke Unit and Stroke Prevention Clinic

Referrals completed by interprofessional team prior to discharge

Durham Region Resource Guide for Individuals Living with Stroke available on Integrated Stroke Unit and can be accessed upon returning to the community on the www.lakeridgehealth.on.ca “Stroke Care” community page.

10.6 The team effectively transfers information

about diagnosis, tests, interventions,

medications, referrals, psychosocial status,

and family situation to the clients’ primary care

providers.

Family Physicians in Durham Region have access to Electronic Medical Record

Patients/Family provided with a copy of the Lakeridge Health Discharge Instruction Record

10.7 When referred to inpatient rehab services,

team effectively transfers information about

pre-hospital history, history of onset, update on

diagnosis, interventions completed,

outstanding tests to be done, current

Electronic Medical record completed in Meditech is available throughout the continuum of care (prevention, acute, rehabilitation, outpatient rehabilitation)

Referrals completed and/or pending recorded on Integrated Stroke Unit patient board at nursing station

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medications and medication changes, family

situation, psychosocial status, and referrals

done or pending.

10.8 When programs are available, the team

assesses clients for early supported DC

according to eligibility criteria.

Currently no Early Support Discharge Programs currently available in the Durham Region

District Stroke Coordinator participating in Ontario Stroke Network Provincial Planning Working Group


Maintaining Accessible and Efficient Clinical Information Systems

11.0 The stroke team establishes and uses a stroke clinical information system to monitor client care and management , and plan

acute stroke services:

11.1 The team maintains a clinical information

system that collects information about each

client, including stroke symptoms, treatments

& interventions & disposition across the

continuum of care.

Meditech is the clinical information system that is used.

The Electronic Medical Record follows patient across the continuum (prevention, acute care, rehabilitation and outpatient rehabilitation)

11.2 The team uses the clinical information system

to gather and organize information across the

continuum of stroke services.

Meditech is the clinical information system that is used

The Electronic Medical Record follows patient across the continuum (prevention, acute care, rehabilitation)

Stroke View can be used to track standardized outcome measures

11.3 The clinical information system is linked to Evidence Based Guidelines and Screening tools incorporated

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decision support tools such as evidence based

guidelines & screening tools for stroke.

into the electronic medical record including PHQ-9, TOR-BSST©, CNS, SADQ-10, Alpha FIM, BERG, MOCA, MMSE)

Interprofessional team documentation screens capture elements outlined in the Interprofessional Clinical Pathway for Ischemic Stroke (5 Acute Days)

11.4 The team uses clinical information system to

obtain information about client risk factors,

appropriate stroke management & intervention

and to schedule appointments for clients &

families.

Information about risk factors, appropriate stroke management and intervention available through the electronic medical record and in the Interprofessional Clinical Pathway for Ischemic Stroke (5 Acute Days)

Diagnostics, tests, referrals and Stroke Prevention Clinic appointments are scheduled through Meditech

11.5 The team uses information from clinical

information system to create reports about

stroke system performance & use of decision

support tools.

Reports have been created in Meditech to review, track and trend data on Alpha FIM, TOR-BSST ©, PHQ-9, SAD-10, MOCA and MMSE

Data available for tPA Administrations (door to CT, Door to Needle, Door to monitored bed)

Reports run to review, monitor and trend data on stroke cases coded as “Non-Specified Strokes”

11.6 The team shares these reports about stroke

system performance & use of decision support

tools within the acute service site & with clients

and families, primary care providers and

community – based services.

Stroke Distinction Scorecard posted on the Continuous Quality Improvement Boards in Emergency Department, Diagnostic Imaging Integrated Stroke Unit and Critical Care

tPA Quarterly Memo shared posted on Emergency Department and Critical Care Continuous Quality Improvement Boards

Stroke Prevention Clinic Performance Metrics posted on Quality Improvement Board in clinic

Stroke Distinction Scorecard posted on the Accreditation

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intranet

Ontario Stroke Network Central East LHIN Stroke Report Card is posted on the District Stroke Centre intranet site and shared annually with the Durham District Stroke Council

Continuous Quality Improvement Boards located in Emergency Department, Integrated Stroke Unit, Diagnostic Imaging and the Stroke Prevention Clinic in locations visible to staff member, patient and families

11.7 The team has security back-up &

confidentiality systems in place for the stroke

data to meet legislation for protecting privacy &

integrity of information.

Institute for Clinical Evaluative Sciences (ICES) Privacy Policy. Data is collected in accordance with the Data Sharing Agreement between Lakeridge Health and Institute for Clinical Evaluative Sciences

Lakeridge Health Privacy Advisory must be accepted prior to accessing Meditech

Lakeridge Health Statement of Confidentiality is signed upon employment

Lakeridge Health Colleague Commitment was completed in uLearn by Lakeridge Health Staff prior to September 30th, 2015. The purpose of the in module is to provide an overview of the following key policies and programs that we have in place to help create and maintain a healthy workplace at Lakeridge Health. Modules included; Respectful Workplace Policies, Privacy and Confidentiality; Accessibility and Patient Declaration of Values

Lakeridge Health Record Retention and Destruction Policy and Procedures

Health Information Management adhere to privacy regulations as outlined by the Information and Privacy Commissioner Data quality assurance processes are in place to ensure quality coding practices (i.e. Data Sources Manual for Special Project

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CIHI 340 & 740: A District Stroke Centre Initiative to Support Accuracy of Stroke Performance Measures Data)


Monitoring Quality and Achieving Positive Outcomes

12.0 The acute stroke team uses data to monitor quality and achieve positive outcomes:

12.1 The team accesses & reviews clinical &

service utilization data. Stroke Distinction Scorecard

Lakeridge Health Program Scorecards (Emergency Department, Critical Care and Post Acute Speciality Services) include stroke specific metrics

tPA Quarterly Memo

Stroke Prevention Clinic Performance Metrics

12.2 The team identifies & monitors standardized

process & outcome performance measures for

acute stroke services.

Stroke Distinction Scorecard

Lakeridge Health Program Scorecards (Emergency Department, Critical Care and Post Acute Speciality Services) include stroke specific metrics

tPA Quarterly Memos

Continuous Quality Improvement Boards located in Emergency Department, Integrated Stroke Unit, Diagnostic Imaging and the Stroke Prevention Clinic

12.3 The team develops action plans for indicators

that have not met performance thresholds. As per Accreditation Canada action plans are required for

ongoing indicator submissions. For example, if in follow up submissions for indicators, only 2/4 rehab indicators were met then you would have to submit an action plan for one of the 2

35


unmet indicators. For the onsite survey, distinction is achieved at onsite survey by meeting the thresholds for the minimum number of indicators (e.g. 7 of 9 acute core indicators)

12.4 The team conducts research, clinical trials, &

assessments of new interventions to find

innovations in acute stroke services.

Lakeridge Health Integrated Stroke Unit is currently involved one active research study; Clinician evaluation of the Swaltek* Air Pulse Therapy device in subjects with swallowing impairment secondary to cerebral vascular accident

Lakeridge Health District Stroke Centre has approval to commence with two additional research studies; Clinical Feasibility and Usability of MyndMove Therapy for Functional Electrical Stimulation Facilitated Treatment of Functional Electrical Stimulation Facilitated Treatment of Subacute and Chronic Severe Hemiparesis of the Upper Limb following Stroke and The experience of organizations undergoing the Stroke Distinction process - a qualitative descriptive study

Lakeridge Health Stroke Prevention Clinic conducting data analysis on closed research study; Stroke Prevention Clinic: a retrospective study of patients’ compliance with stroke prevention treatment

Lakeridge Health District Stroke Centre presented 2 posters at the 2015 Canadian Stroke Congress; Investigating the Feasibility of a 9-week Community-Based Exercise Program for Persons with Stroke, and a 9-week Support Program for their Caregivers and Using stroke thrombolysis to describe independent physician learning of a cognitive skill: a retrospective cohort study.

District Stroke Coordinator participated in three Ontario Stroke Network poster presentations at the 2015 Canadian Stroke Congress; A Provincial Collaboration to Enhance Stroke Early

36


Supported Discharge Knowledge and Resources, Implementing a Coordinated Approach to Collecting Stroke Rehabilitation Intensity Data across Ontario and Evaluating the Clinical Experience of Stroke Rehabilitation Intensity Data Collection in Ontario

Research Binder available in Patient Care Manager Office on the Integrated Stroke Unit

12.5 The team monitors client & family perspectives

on the quality of stroke services.

Patient and Family Satisfaction Survey Surveys being completed on iPads prior to discharge from Integrated Stroke Unit and Stroke Prevention Clinic

12.6 The team compares its results on performance

indicators with other similar acute stroke

services or sites.

Ontario Stroke Report Card

Ontario Stroke Network Central East Local Health Integration Network Report Card

Participation in Central East Stroke Network Steering Committee

12.7 The team uses information it collects about the

quality of services to identify successes &

opportunities for improvement & makes

improvements in a timely way.

Stroke Navigation Line calls utilized to determine process improvement opportunities

iPAD patient/family satisfaction surveys completed on the Integrated Stroke Unit and in the Stroke Prevention Clinic

Huddles (Emergency Department) and Daily Rounding used to monitor for immediate process improvement

Stroke Distinction Metrics Working Group bring monthly updates to the Stroke Distinction Sub-Committee

Lakeridge Health Stroke Distinction Score Card and Quality Based Funding Metrics, and Lakeridge Health Program Scorecards data is monitored, trended and used to identify areas of improvement

37


12.8 The team shares evaluation results with staff,

clients & families. Information is posted on Continuous Quality Improvement

Boards Emergency Department, Critical Care and Integrated Stroke Unit

tPA Process Improvement Memos shared with physicians involved in administration and review team

tPA quarterly and fiscal year end statistics memo shared with Emergency Department, Critical Care and Stroke Physician Lead

Ontario Stroke Network and Central East Local Health Integration Network Report Cards are posted on the Lakeridge Health intranet and presented annually to the Durham District Stroke Council

1

Rehabilitation Standards Overview


Investing in Comprehensive Stroke Rehabilitation Services

1.0 The site collects and analyzes information about the need for inpatient stroke services:

1.1 The site annually collects information about stroke incidence in the population it serves.

Lakeridge Health participates in CIHI 340 and 740 Mandatory Reporting

Stroke Prevention Clinic Performance Indicators (wait times, referrals, visits, patient satisfaction, priority status, referral source)

Decision Support, District Stroke Coordinator & Quality Coordinator report data at Post-Acute Specialty Services Council

Stroke Distinction Metrics Scorecard reported monthly to the Stroke Distinction Sub-Committee by Metrics Working Group

Durham District Stroke Centre Reporting to the Durham District Stroke Council

Participation in 2009/10 - 11/12 Ontario Stroke Audit Participation in 2011-12 Stroke Prevention Clinic Audit

Participation in Ontario Stroke Network Stroke Report Card analysis and interpretation for Central East LHIN http://thewave.corp.lakeridgehealth.on.ca/news/Pages/High-Marks-for-Stroke-Care-at-Lakeridge-Health.aspx

1.2 When planning stroke services the site collects information about the prevalence of major risk factors for stroke in the population it serves.

Data from Statistics Canada and Central East LHIN utilized to review and guide Lakeridge Health Stroke Services

Heart and Stroke Foundation Reports on Canadian Stroke Health

Heart Association Stroke Journal

2


1.3 The site collects demographic information about high- risk and hard-to-reach populations.

Alignment of Lakeridge Health with Central East Stroke Network (CESN) and Ontario Stroke Network (OSN) work plans

Durham District Stroke Council as representation from, Self-Management, Heart and Stroke Foundation, COPE Mental Health, March of Dimes, Stroke Survivor, Emergency Department, Emergency Medical Services, Oshawa Seniors Citizens Centre and Brain Injury Association

Durham District Stroke Coordinator member of Central East Acquired Brain Injury Network

1.4 The site uses information about demand for inpatient stroke rehabilitation services to identify and analyze barriers that prevent access to services.

Durham District Stroke Coordinator member of Central East LHIN Stroke Working Group for stroke system redesign

Central East Stroke Network Work Plan 2014-2015

Lakeridge Health Daily Stroke Admissions report for all sites

Lakeridge Health Automated Wait List http://thewave.corp.lakeridgehealth.on.ca/howdoi/Pages/Add-a-patient-to-the-PASS-Automated-Wait-List-(AWL).aspx

Lakeridge Health Bed Management Policy and Procedure

Integrated Stroke Unit minimizes impact on barriers to rehabilitation as patients are on one geographical unit with the same interprofessional team

3

Standard Evidence

Engaging a Prepared and Proactive Stroke Rehabilitation Team

2.0 The stroke rehabilitation team uses an interprofessional approach to coordinate and deliver inpatient stroke rehabilitation services:

2.1 The team has adopted and implemented the Canadian Best Practice Recommendations for Stroke Care for the assessment and management of stroke clients.

Canadian Neurological Scale, NIHSS, PHQ-9, Alpha-FIM, CMSA, Follow 30 Day Rehabilitation Clinical Pathway for Ischemic Stroke, Non-Alteplase PPO for admission.

Continuing education sessions provided to all Lakeridge Health staff (Provincial Stroke Rounds, Central East Stroke Network Rounds, National Stroke Rounds, Stroke Education Day)

Ongoing participation in research (Stroke Prevention Clinic & Integrated Stroke Unit)

Code Stroke Box in Critical Care for In-House Code Strokes

2.2 The team has expertise in stroke care and uses an interprofessional approach to deliver inpatient stroke rehabilitation to clients and families.

Integrated Stroke Unit Interprofessional team includes Physicians (Hospitalist, Physiatrists and Neurologists), Nursing (RN and RPN), OT, PT, SLP, Rehabilitation Assistants, Social Work, Pharmacist, Clinical Nurse Specialist. Neuropsychologist, ethicist & Chaplain available on consultation https://www.youtube.com/playlist?list=PL2jY9UzvBjU2Gy9k-ul9bPO6lWGwbft2Y

2.3 The team has clearly defined roles & responsibilities for delivering stroke services to client, family/caregiver.

Team roles and responsibilities outlined in the Interprofessional Clinical Pathway for Stroke Inpatient Rehabilitation (5 weeks)

A video of meet the stroke team has been created to help clarify the roles of the team members to patients and families

2.4 Each team member has the necessary credentials or license from the appropriate

Human Resources receive information on Nurse &

4

Standard Evidence

college or association. Interprofessional Practice for allied health care members for members not in good standing. Information reported to employee manager

Credentials are checked annually and maintained by Human Resources

New hires have vulnerable sector check completed

2.5 The team orients new staff & service providers about the unique aspects of stroke rehabilitation services.

All new Lakeridge Health Staff receives Interprofessional orientation to the stroke services at Lakeridge health

Integrated Stroke Unit Specific Orientation (ISU Orientation Process Map)

Code Stroke/Critical Care Clinical Assistance Orientation Package

All new staff must attend a stroke workshop either at Lakeridge Health or at Peterborough Regional Health Care Centre

All new staff of the ISU are asked to review stroke materials prior to working on the unit

2.6 The team receives ongoing professional development & training to deliver current evidence based stroke rehabilitation services.

Continuing education sessions provided to all Lakeridge Health staff (Provincial Stroke Rounds, Central East Stroke Network Rounds, National Stroke Rounds, Grand Rounds, Stroke Education Day)

Centralized education sessions for TOR-BSST©, Canadian Neurological Scale and Post Stroke Depression

Unit Huddles

Signs of Stroke and In-House Code Stroke procedure included in Lakeridge Health Passport to Safety and uLearn (Lakeridge Health Learning Management System) Module

In-House Code Stroke Mocks and Debriefs

5

Standard Evidence

Mock Tracers utilizing Lakeridge Health Tracer Team

Access to on-line refresher for TOR-BSST© posted on uLearn (Lakeridge Health Learning Management System) for all certified assessors to access

Central East Stroke Network Education Funds utilized to support ongoing education (sponsored 2 Integrated Stroke Unit staff members to attend the 2015 Canadian Stroke Congress)

Toronto Stroke Networks Virtual Community of Practice promoted to staff as a tool for ongoing education http://www.strokecommunity.ca/

Staff encouraged to complete Apex Innovations, Canadian Hemispheres online stroke training and funding for licenses is provided by the Central East Stroke Network and facilitated by the District Stroke Centre https://www.apexinnovations.com/CanadianHemispheres.php

Staff encouraged to complete the online acute stroke management modules through the Southwestern Ontario Stroke Network http://swostroke.ca/acute-stroke-unit-orientation/

Staff encouraged to certify for the National Institutes of Health Stroke Scale through the American Heart Association

2.7 The team uses information from performance evaluations to improve stroke rehabilitation services, & identify support, training, or development of team needs.

Performance appraisals completed every 2 years or sooner if need arises using Lakeridge Health standardized tool as per outlined in the Performance Assessment and Development Policy and Procedure

Ongoing performance management

6

Standard Evidence

3.0 The Interprofessional team providing inpatient stroke rehabilitation has support from leadership and resources to provide effective services:

3.1 The interdisciplinary team providing stroke rehabilitation services has a designated coordinator.

Integrated Stroke Unit Patient Care Manager (Mary McAvoy)

Integrated Stroke Unit Patient Care Specialist (Angela Buffet)

Stroke Physician Lead (Dr. Leo Chiu)

District Stroke Coordinator (Amy Maebrae-Waller)

District Stroke Centre Clinical Nurse Specialist (Anna Sewell)

Chief of Neurology (Dr. David Crisp)

Medical Director, Post-Acute Specialty Services (Dr. Luigi Pedretti)

3.2 The team works with staff, other service providers, & community partners to develop goals & objectives for stroke rehabilitation services that align with the site’s strategic & operational plans.

Lakeridge Health Ambulatory Rehabilitation Centre (ARC) Outpatient Neurology Services (Rehabilitation Services, Physiatry Follow-Up Clinic & EMG/Spasticity Clinic)

Lakeridge Health Stroke Prevention Clinic

Durham District Stroke Council

Post-Acute Specialty Services Council & Quality Committee

March of Dimes Stroke Recovery Canada, Oshawa Support Group, COPE Community Care Durham and Lifeline provide support to the Integrated Stroke Unit (visit patients, provide education sessions)

3.3 The team has resources to establish & support dedicated stroke units for inpatient stroke rehabilitation services.

28 bed (5 acute and 23 rehabilitation) Integrated Stroke Unit located on OC5

Dedicated interprofessional team

3.4 The layout of the physical space contributes to the effectiveness & safety of stroke services.

Shared treatment space located on 5A includes; conference room, 3 interprofessional treatment spaces, assessment space,

7

Standard Evidence

patient dining room, activities of daily living kitchen and bathroom

Wide hallways, wheelchair accessible showers and bathrooms, wander guard in place, tab alarms

3.5 When delivering stroke services, the team has access to equipment & supplies appropriate to the needs of the stroke clients & the population it serves.

Dedicated budget for Integrated Stroke Unit

Integrated Stroke Unit has access to the Lakeridge Health Central Equipment Management (wheelchairs, lifts and transfer devices, bariatric equipment, V.A.C. Therapy devices, specialty surfaces and beds)

Annual review of Capital Equipment needs

Lakeridge Health Foundation provides occasional support from donated funds

3.6 The team uses Telehealth to increase access to stroke specialists.

OTN can be utilized on Integrated Stroke Unit as required

Telemedicine consultations available if required

Standard Evidence

4.0 The stroke rehabilitation team collaborates with other services, providers, and organizations to coordinate inpatient stroke rehabilitation services and meet the needs of stroke clients in the community:

4.1 The team collaborates with internal partners including acute stroke rehabilitation services, programs and providers to coordinate rehabilitation services for stroke clients.


Lakeridge Health Stroke Prevention Clinic

Lakeridge Health internet “Stroke Care” Resource Centre

Lakeridge Health intranet (WAVE) has Integrated Stroke Unit, and District Stroke Centre & Stroke Prevention Clinic pages

8

Standard Evidence

Integrated Stroke Unit collaborates with; Ethicist, Neuropsychologist, Diabetes Network, Geriatrician, Geriatric Assessment and Intervention Network Clinic, Cardiac Rehabilitation

4.2 The team collaborates with acute hospitals, other rehabilitation sites including sub-acute centres providing complex continuing care or rehabilitation, early supported discharge programs, primary care practitioners, long term care, home care, and community-based services to coordinate and plan inpatient stroke rehabilitation services in the site’s service boundary.

Lakeridge Health has Complex Continuing Care beds at Lakeridge Health Whitby and Lakeridge Health Bowmanville

Lakeridge Health was a Geriatric Assessment Rehabilitation Unit


Community Care Access Centre manages Long Term Care applications

Interprofessional team provides Retirement Home List to patients and caregivers

4.3 The team works with community agencies to sponsor public campaigns to raise awareness about stroke rehabilitation services available in the community, the impact of stroke & living with stroke.

Durham District Community Outreach Activities (2014-2015) and Community Let’s Talk about Stroke, Do You Know the Signs? education sessions

Ontario Stroke Network Stroke Month Communication Plan (2015)

Heart and Stroke FAST Screensavers at Lakeridge Health

Heart and Stroke FAST on all Lakeridge Health lobby televisions

Heart and Stroke FAST and Durham District Poster sent to external partners and community providers

Lakeridge Health “Stroke Care” Resource Bookmark

CE LHIN Healthline Stroke Resource microsite

Lakeridge Health Intranet Articles

Lakeridge Health Social Media tools

9

Standard Evidence

Heart and Stroke FAST Elevator skins on Integrated Stroke Unit elevator doors

Standard Evidence

Providing safe and appropriate Inpatient Stroke Rehabilitation Services

5.0 The stroke team coordinates timely access to inpatient stroke rehabilitation services for clients, families and caregivers, service and referring organizations/providers:

5.1 The team has a formal intake criteria and processes based on standardized assessments.


Lakeridge Health Stroke Triage Model base on standardized tools including Alpha FIM ® assessment completed on Day 3

Post-Acute Specialty Services Program Admission Criteria

5.2 The team communicates referral processes & intake criteria for inpatient stroke rehabilitation to all referring centres, including acute care providers, complex continuing care, long term care homes, home care services, as well as to clients & families.

Post-Acute Specialty Services Program Admission Criteria is posted on the Lakeridge Health intranet and external website

Greater Toronto Area (GTA) Rehabilitation Network Referring Guidelines www.gtarehabnetwork.ca

Discharge Support Meeting Tool (DSMT)

Patient Transfer Record completed by Integrated Stroke Unit when completing a non-emergency transfer

5.3 The team contacts referring centres & responds within 48 hours to requests for rehabilitation services.

Requests for repatriation to external facilitates are completed by the Operations Supervisor in the Lakeridge Health Patient Flow Office

Internal referrals to the Integrated Stroke Unit are completed through the Automated Wait List

10

Standard Evidence

http://thewave.corp.lakeridgehealth.on.ca/howdoi/Pages/Add-a-patient-to-the-PASS-Automated-Wait-List-(AWL).aspx

External referrals from within the Central East Local Health Integrated Network (Central East LHIN) are completed through the RMAR

External referrals from outside the Central East Local Health Integrated Network (Central East LHIN) are completed using E-Stroke

5.4 The wait time from when a client has met criteria for being “rehab ready” by until admission to inpatient rehabilitation services not more than 2 business days.

Patients admitted to the Integrated Stroke Unit are assessed by the interdisciplinary team on day 1 as per the Interprofessional Clinical Pathway for Stroke Inpatient Rehabilitation (5 weeks)

Acute patients are transferred to inpatient rehabilitation status on or before day 5 as per the Interprofessional Clinical Pathway for Ischemic Stroke (5 Acute Days)

If a patient is located on another unit within Lakeridge Health, and requires inpatient stroke rehabilitation services, they are place on the automated wait list, and they are transferred to the Integrated Stroke Unit when a bed becomes available http://thewave.corp.lakeridgehealth.on.ca/howdoi/Pages/Add-a-patient-to-the-PASS-Automated-Wait-List-(AWL).aspx

Resource Matching and Referral is utilized to facilitate transfers to the Integrated Stroke Unit

5.5 The team monitors its responsiveness by setting and tracking times for responding to requests for services and information.



Regular communication with Operations Supervisor in Patient Flow Office regarding stroke/TIA patients waiting for admissions

11

Standard Evidence

Time of transfer from Emergency Department to Integrated Stroke Unit is monitored and posted on the Post-Acute Specialty Program Scorecard on the intranet https://lh-web-app/scorecard/Scorecard.aspx?ScorecardID=25&ReportingTimeFrame=Quarterly&Population=1&Quarter=2015 - 2016 Q2

Stroke Distinction Scorecard identifies the proportion of patients treated on the dedicated stroke unit

5.6 The team regularly reviews the needs of stroke clients for services and responds quickly to those who are in emergency or crisis situation.



Regular communication with Operations Supervisor in Patient Flow Office regarding stroke/TIA patients waiting for admissions

Time of transfer from Emergency Department to Integrated Stroke Unit is monitored and posted on the Post-Acute Specialty Program Scorecard on the intranet https://lh-web-app/scorecard/Scorecard.aspx?ScorecardID=25&ReportingTimeFrame=Quarterly&Population=1&Quarter=2015 - 2016 Q2

5.7 The team establishes partnerships or collaborations required to regularly monitor & reassess survivors of moderate or severe strokes who did not meet criteria for inpatient rehabilitation at the first assessment, & provides input on the client’s status & ongoing rehabilitation needs.


Lakeridge Health Integrated Stroke Unit Triage Tool utilized by interprofessional team members

Alpha FIM ® is completed by the interprofessional team on Day 3 and used to predict outcomes

Referrals from other Lakeridge Health Units and/or external

12

Standard Evidence

facilities reviewed by Patient Care Manager and/or Patient Care Specialist

Referrals for appropriate community supports (homecare or Outpatients) completed prior to discharge home

5.8 The team has a process for stroke survivors to re-access stroke rehabilitation if clinically indicated regardless of the time that has elapsed since the stroke.

Stroke survivors who are living in the community that need to re-access inpatient rehabilitation services do so through the Emergency Department or the Stroke Prevention Clinic

Stroke Navigation Line telephone number is provide to all Integrated Stroke Unit patient and caregivers upon discharge home to assist with issues and concerns that may arise following their discharge home

The Integrated Stroke Unit partners with the Community Care Access Centre (homecare) and Ambulatory Rehabilitation Centre (ARC- Neuro) to provide rehabilitation services upon discharge

Standard Evidence

6.0 The stroke rehabilitation team accurately and appropriately assesses clients to develop an individualized care plan for stroke rehabilitation:

6.1 From time of first contact, the team informs client & family of the interprofessional team member who has primary responsibility for coordinating the stroke rehabilitation services & provides information on how to contact that person.

Patient Care Manager and Patient Care Specialist are located on the Integrated Stroke Unit and are available for patients and family members

Patients and caregivers are provided a copy of the Discharge Support Letter

Names of interprofessional team members working with the patient are written on white board at the patients beside and updated as required

13

Standard Evidence

Welcome to the Integrated Stroke Unit pamphlet is included in the patient education materials

Pictures of the interprofessional team are posted at the entrance of the Integrated Stroke Unit

Meet Your Stroke Care Team Video is included in the patient education video series https://www.youtube.com/playlist?list=PL2jY9UzvBjU2Gy9k-ul9bPO6lWGwbft2Y

6.2 The team assesses the client’s stroke related impairments and functional status within 24 to 48 hours of admission.



Lakeridge Health Mobility Standard of Care (Adults) and Mobility Algorithm

Mobility and functional status is recorded on patient communication boards at bedside

6.3 The team conducts functional assessments using a standardized and valid assessment tools.

Interprofessional Clinical Pathway for Stroke Inpatient Rehabilitation (5 weeks) outlines standardized tools to be completed by the interprofessional team

Functional Independence Measure (FIM) completed within 72 hours of admission and discharge

6.4 The team screens high-risk clients for cognitive impairment using a validated tool during their inpatient rehabilitation stay, at all transition points, and whenever clinical presentation indicates.



Completion of cognitive screening is tracked on “Stroke View” in

14

Standard Evidence

Meditech patient record



6.5 The team refers clients identified with cognitive impairment during screening to a health care professional with expertise in cognition for further assessment, diagnosis, & development of a treatment plan.



6.6 The team screens clients for depression using a validated screening tool during inpatient rehabilitation stay, at all transition points & whenever clinical presentation indicates.







Post Stroke Depression education included in Interprofessional Education Calendar

6.7 The team refers clients identified as at risk for depression during screening to a health care professional with expertise in mental health for


Upon discharge from inpatients follow up at Lakeridge Health

15

Standard Evidence

further assessment, diagnosis & development of a treatment plan.

Ambulatory Rehabilitation Centre Physiatrists Clinics can be utilized

6.8 The team develops an individualized rehabilitation plan based on the clients’ functional assessment that identifies required rehabilitation services, intensity & duration of therapy & rehabilitation therapy goals.

Lakeridge Health Integrated Stroke Unit Triage Tool utilized by interprofessional team members

Alpha FIM ® is completed by the interprofessional team on Day 3 and used to predict outcomes

Functional Independence Measure (FIM) completed within 72 hours of admission and discharge

Integrated Stroke Unit was an early adopter and pilot site for the Ontario Stroke Network Rehabilitation Intensity data collection project

Rehab Intensity Minutes (RIM) captured by interprofessional team in Meditech screen

Discharge dates are posted on patients communication board at bedside and timeframes and recommendation are based on best practice and patient goals

Discharge Support Meeting held early in each patient’s rehabilitation stay to discuss rehab goals

6.9 The team includes discharge planning in each client’s rehabilitation plan by identifying transition issues specific to the client & family, caregiver training needs, safety & organizing home visits by health care professionals to assess the home environment.

Interprofessional team rounds held every Tuesday and Thursday at 11:00 barriers to discharge, support services and referrals to be completed prior to discharge are discussed and recorded on rounds board in order to make information available for all team members

Discharge Support Meeting Checklist is utilized to assist with discharge planning

Community and Self-Management Resource Guide are included in Integrated Stroke Unite patient education packages

16

Standard Evidence

Weekend and/or day passes are encouraged prior to patient’s discharge

Interprofessional team or Community Care Access Centre will complete home assessments and make recommendations as required

6.10 The team conducts at least one formal interprofessional meeting per week to monitor client’s progress in achieving their rehabilitation goals.

Interprofessional team rounds are held every Tuesday and Thursday at 1100

6.11 The team, clients, family & caregivers regularly update the written rehabilitation plan on the progress made towards client goals & anticipated discharge timing & destination.

Weekly patient goals written on white board in patient room and team communication board

Discharge support meeting date is given to patients and caregivers early in the patients stay

6.12 When client rehabilitation goals are not met, the team documents the reasons & updates the rehabilitation goals, discharge timing, and destination plans as appropriate.

Alpha-FIM® score results discussed in discharge support meeting

Rehabilitation plans are discussed at time of assessment, with patients and documented in patient chart and followed up during interdisciplinary patient rounds

If goals are not met, remediation strategies are put into place. (i.e. if goal is medication management and patient was not able to meet that goal, prompted medication administration system put into place)

17

Standard Evidence

7.0 The stroke team provides comprehensive, safe and timely inpatient stroke rehabilitation.

7.1 Clients admitted for inpatient stroke rehabilitation services are managed on a dedicated acute stroke unit.

Integrated Stroke Unit located on OC5 (5 acute beds, 23 rehab beds)

7.2 When clients are not managed on a dedicated stroke unit there is a process for clustering stroke patients.

Not applicable

7.3 When the team provides rehabilitative stroke care on general rehabilitation units or mixed units, protocols are used that are specific to the care and management of stroke clients.

Not applicable – Integrated Stroke Unit

7.4 Team members deliver the appropriate intensity and duration of clinically relevant therapies across the care of continuum as prescribed in the individualized rehabilitation plan.

Alpha FIM® score is considered when developing individualize treatment plans

Rehabilitation plans are discussed at time of assessment, with patients and documented in patient chart and followed up during interdisciplinary patient rounds

Integrated Stroke Unit participated as a pilot site for the Ontario Stroke Network Rehabilitation Intensity data collection project resulting in the unit being an early adopter to collecting rehabilitation intensity data

Posters presented at 2015 Canadian Stroke Congress

7.5 The team delivers a minimum of one hour of direct therapy for each relevant core therapy, a minimum of five days per week to each stroke rehabilitation client.

Patient schedule on communication board at bedside

Monitor rehabilitation intensity in Meditech

Patient goals are posted on communication board at bedside

Patient goals are documented during interprofessional rounds

3 physiotherapists, 3 occupational therapists, 2 rehabilitation assistants, 2 speech language pathologist provide therapy 5

18

Standard Evidence

days per week

7.6 The team promotes integrating skills gained in therapy into the clients’ daily routine to increase their participation & activity.

Patient goals posted on the white boards for all team members to see

Allied Health huddles

Teach transfer skills to nursing staff and families

Graded Repetitive Arm Supplementary Program (GRASP) used with appropriate patients

Dressing assessments completed by interprofessional team members

7.7 The team follows established protocols & mechanisms for the safety of stroke clients during inpatient rehabilitation.

The team follows established protocols and mechanisms for the

safety of stroke clients during inpatient rehabilitation including the

following:

Wheelchair and other equipment maintenance (i.e. broken

items tagged)

Infection control audits (CAUTI, Hand Hygiene)

Mobility Standard of Care (Adults)

Mobility signs posted at bedside

Swallowing Precaution Poster Signage

Wander guard

Tab Alarms

Carole high low beds

Bedside falls mats

7.8 The team implements & evaluates a falls prevention strategy specific to stroke clients to minimize the risk of falls in this population.

Lakeridge Health Falls Prevention and Management for Adult Patients (older than 18 years) Policy and Procedures

Morse Falls Scale completed by nursing

Physiotherapist complete BERG Balance Scale on admission to

19

Standard Evidence

Integrated Stroke Unit


Post-fall huddles on Integrated Stroke Unit

7.9 The team assesses each client’s risk for developing a pressure ulcer & implements interventions to prevent pressure ulcer development.

Braden Scale completed by nursing

Access to specialized surfaces through Lakeridge Health Central Equipment Management

Preventing Pressure Ulcers staff materials


Consultation available with Nurse Practitioner with specialization in wound prevention, assessment, management, treatment

Post-Acute Specialty Program monitors incidence of ulcers in Complex Continuing Care and reports rates on Program scorecard

Monitoring proportion of inpatients with stroke that experience pressure ulcers as a complication during inpatient stay as optional Stroke Distinction Metric

Standard Evidence

8.0 The stroke rehabilitation team prepares clients, families and caregivers to address secondary stroke prevention:

8.1 The team provides clients, their family/caregiver with information on lifestyle modifications to address cardiovascular risk factors for recurrent stroke during inpatient rehabilitation.

Education materials included in Integrated Stroke Unit Education Package and reviewed during Stroke Education classes


Individualized teaching to patients and family as required

Referral to Cardiac Rehabilitation (if appropriate) at discharge

20

Standard Evidence

8.2 The team assesses clients for the presence of hypertension & appropriately manages elevated blood pressure during inpatient rehabilitation in all clients with stroke.


Stroke Education Video Series includes educational video on hypertension

8.3 The team assesses clients for the presence of elevated lipid levels & appropriately manages lipid levels in all clients with stroke.


Stroke Education Video series includes educational video on cholesterol

Educational materials available on display board on Integrated Stroke Unit and in the Stroke Prevention Clinic

8.4 The team prescribes all adult clients with ischemic stroke or TIA with antiplatelet therapy for secondary prevention of stroke of recurrent stroke unless there are contraindications for anticoagulation.


Patient Education sheets available on the District Stroke Centre intranet site


8.5 The team assesses & manages diabetes in clients admitted to rehabilitation in accordance with the current Canadian Diabetes Association recommendations for the management of diabetes.


Referral to Central East Community Care Access Centre Diabetes Centre completed upon discharge if required

8.6 The team treats adult clients with stroke and atrial fibrillation with anticoagulants unless contraindicated.


8.7 The team addresses compliance with the anticoagulation regimen with all stroke clients and their families/caregivers in their follow up

Patients/caregivers are provided with the Your Stroke Journey book in the Integrated Stroke Unit education package

Stroke Education Video series includes education on

21

Standard Evidence

with clients. anticoagulants and antiplatelets


8.8 The team follows mechanisms for referrals and follow-up for clients who are admitted to inpatient rehabilitation with carotid stenosis requiring possible surgical intervention.

Criticall utilized for consultation

Stroke Prevention Clinic organizes consultation with the Vascular Surgery Office in Peterborough

8.9 The team has a process to assess and determine smoking status and provides information on smoking cessation.

Smoking status assessed on admission to Integrated Stroke Unit

Nicotine replacement offered to patients

Smoking Cessation resources from the Canadian Cancer society and The Lung Association available on Integrated Stroke Unit and in the Stroke Prevention Clinic (available in multiple languages)

Standard Evidence

Helping Clients and Families Live with Stroke

9.0 The stroke rehabilitation team assesses and manages potential sequence of stroke in an accurate and safe manner:

9.1 The team screens and documents the clients’ swallowing ability using a simple valid reliable testing protocol as part of their initial rehabilitation assessment.


TOR-BSST© used for dysphagia screening (Emergency Department uses paper tool, Critical Care/Integrated Stroke Unit)

Swallowing Precaution Poster utilized on Integrated Stroke Unit

Dysphagia Policy and Procedure for Suspected and/or Acute Stroke

9.2 The team refers clients with signs of dysphagia TOR-BSST© used for dysphagia screening, failure triggers

22

Standard Evidence

or pulmonary aspiration for a full clinical swallowing assessment of their swallowing ability by a speech-language pathologist or appropriately trained specialist who should advise on swallowing ability and consistency of diet and fluids.

automatic referral to SLP and Dietitian

Integrated Stroke Unit participating in “Clinician Evaluation of the Swaltek* Air Pulse Therapy Device in Subjects with Swallowing lmpairment Secondary to Cerebral Vascular Accident” research study

Modified Barium Swallowing Tests can be completed in collaboration with Lakeridge Health Diagnostic Imaging Department

9.3 The team refers clients at risk of malnutrition, including those with dysphagia, to a dietitian for assessment and ongoing management.

Malnutrition Screening Tool (MST) included in Ischemic Stroke – Non-Alteplase/Post Alteplase (Greater than 24 hours) Admission Orders Pre Printed Order Set.

Failure of Malnutrition Screening Tool automatically triggers a referral to Dietitian

9.4 The team screens clients with stroke for depression at all transition points and whenever clinical presentation indicates.



Screening rates and monthly goals are posted on Integrated Stroke Unit Continuous Quality Improvement Board Post Stroke Depression education included in Interprofessional Education Calendar


9.5 The team refers clients identified as high risk for depression during screening to a psychiatrist, psychologist, or social worker for further


Upon discharge from inpatients follow up at Lakeridge Health

23

Standard Evidence

assessment, diagnosis & development of a treatment plan

Ambulatory Rehabilitation Centre Physiatrist Clinics can be utilized

9.6 Clients who demonstrate cognitive impairments in the screening process are referred to professional with specific expertise for additional cognitive, perceptual & functional assessment to determine the severity of the impairment and impact on function & safety in activities of daily living and instrumental activities of daily living & to implement appropriate remedial, compensatory and adaptive intervention strategies.

Interprofessional Clinical Pathway for Stroke Inpatient Rehabilitation Stroke (5 weeks)







Standard Evidence

10.0 The stroke rehabilitation team effectively integrates clients and families into the community after inpatient stroke rehabilitation:

10.1 The team works with client, family & caregivers to develop a transition & follow up plan that includes referrals for additional follow up services, & individual exercise program.


Integrated Stroke Unit Education packages include information on signs of stroke (FAST Magnet) and stroke recovery (Your Stroke Journey)


24

Standard Evidence

Integrated Stroke Unit patients provided with Stroke Navigation Telephone Number (included on Discharge Support Meeting Tool)

Referrals sent to at Ambulatory Rehabilitation Centre (ARC), Community Care Access Centre, Stroke Prevention Clinic or Together in Movement and Exercise Programs for outpatient rehabilitation and exercise services

10.2 The team provides stroke clients, families & caregivers with written discharge information regarding ongoing recovery, action plans, goals, signs and symptoms of declining health status, & contact information for follow up with the team.


Integrated Stroke Unit Education packages include information on signs of stroke (FAST Magnet) and stroke recovery (Your Stroke Journey)



Referrals sent to at Ambulatory Rehabilitation Centre (ARC), Community Care Access Centre or Together in Movement and Exercise Programs for outpatient rehabilitation and exercise services

10.3 The team provides clients, families and caregivers with education and support to identify and adjust to changes in roles and lifestyles




March of Dimes Stroke Recovery Canada, Community Care Durham and Lifeline host presentations and visit Integrated

25

Standard Evidence

Stroke Unit



Educational information and resources available on resource board display on Integrated Stroke Unit

Durham District Community Resource Guide for Individuals Living with Stroke and their Caregivers available on Integrated Stroke Unit and “Stroke Resources” section of www.lakeridgehealth.on.ca

10.4 The team provides education that promotes self-efficacy through mastering self-management skills.







Educational information and resources available on resource board display on Integrated Stroke Unit Durham District Community Resource Guide for Individuals Living with Stroke and their Caregivers available on Integrated Stroke Unit and “Stroke Resources” section of www.lakeridgehealth.on.ca

26

Standard Evidence

10.5 The team provides training to family and caregivers to safely care for clients after discharge.

Tips and Tools for Everyday Living: A Guide for Stroke Caregivers is available on the Integrated Stroke Unit

Family and Team Case Decision Support Meetings

Overnight passes with family prior to discharge

Medication teaching and management counselling

Group Education Classes for patients and families

Individualized training with staff to address specific needs ( e.g. transfers/mobility, safe feeding, supportive communication and ostomy care)

If required the Community Care Access Centre or the Integrated Stroke Unit Interprofessional team can complete home visit prior to discharge

10.6 The team provides clients, families & caregivers with a list of primary care physicians, community based rehabilitation, home care services, psychological counseling, caregiver training, stroke support groups & vocational counseling services in the community.







Educational information and resources available on resource board display on Integrated Stroke Unit Durham District Community Resource Guide for Individuals Living with Stroke and their Caregivers available on Integrated

27

Standard Evidence

Stroke Unit and “Stroke Resources” section of www.lakeridgehealth.on.ca

10.7 The team works with clients, families & caregivers to help them access primary care, home & community services, community-based rehabilitation & psychological counseling services







Educational information and resources available on resource board display on Integrated Stroke Unit Durham District Community Resource Guide for Individuals Living with Stroke and their Caregivers available on Integrated Stroke Unit and “Stroke Resources” section of www.lakeridgehealth.on.ca

10.8 The team coordinates referral for follow-up secondary prevention required by clients before leaving inpatient stroke rehabilitation.

Integrated Stroke Unit completes electronic referral to Lakeridge Health Stroke Prevention Clinic prior to discharge

10.9 Following transition or end of service, the team contacts clients & families to evaluate the effectiveness of the transition & uses the


28

Standard Evidence

information to improve its transition and end-of-service planning.

Patient and Family Satisfaction Survey Surveys being completed on iPads prior to discharge from Integrated Stroke Unit and Stroke Prevention Clinic

Emergency Department Satisfaction Surveys (National Research Canada Picker)

Standard Evidence

Maintaining Accessible and Efficient Clinical Information Systems

11.0 The team establishes and uses a stroke clinical information system to monitor client care and management , and plan inpatient stroke rehabilitation services:

11.1 The team maintains a clinical information system that collects information about each client, including stroke symptoms, treatments & interventions.

Meditech is the clinical information system that is used.

The Electronic Medical Record follows patient across the continuum (prevention, acute care, rehabilitation and outpatient rehabilitation)

11.2 The team gathers and organizes information in the clinical information system across the continuum of stroke services.

Meditech is the clinical information system that is used

The Electronic Medical Record follows patient across the continuum (prevention, acute care, rehabilitation)

Stroke View can be used to track standardized outcome measures

11.3 The clinical information system is linked to decision support tools such as evidence based guidelines & screening tools for stroke.

Evidence Based Guidelines and Screening tools incorporated into the electronic medical record including PHQ-9, TOR-BSST©, CNS, SADQ-10, Alpha FIM, BERG, MOCA, MMSE)

Interprofessional team documentation screens capture elements outlined in the Interprofessional Clinical Pathway for Stroke

29

Standard Evidence

Inpatient Rehabilitation (5 weeks)

11.4 The team uses clinical information system to obtain information about client risk factors, appropriate stroke management & intervention and to schedule appointments for clients & families.

Information about risk factors, appropriate stroke management and intervention available through the electronic medical record and in the Interprofessional Clinical Pathway for Stroke Inpatient Rehabilitation(5 weeks)

Diagnostics, tests, referrals and Stroke Prevention Clinic appointments are scheduled through Meditech

11.5 The team uses information from clinical information system to create reports about stroke system performance & use of decision support tools.

Reports have been created in Meditech to review, track and trend data on Alpha FIM®, TOR-BSST©, PHQ-9, SAD-10, MOCA and MMSE

11.6 The team shares these reports about stroke system performance & use of decision support tools within the rehabilitation site & with clients and families, primary care providers and community – based services.

Stroke Distinction Scorecard posted on the Continuous Quality Improvement Boards in Emergency Department, Diagnostic Imaging Integrated Stroke Unit and Critical Care

Stroke Prevention Clinic Performance Metrics posted on Quality Improvement Board in clinic

Stroke Distinction Scorecard posted on the Accreditation intranet

Ontario Stroke Network Central East Local Health Integration Network Stroke Report Card is posted on the District Stroke Centre intranet site and shared annually with the Durham District Stroke Council

Continuous Quality Improvement Boards located in Emergency Department, Integrated Stroke Unit, Diagnostic Imaging and the Stroke Prevention Clinic in locations visible to staff member, patient and families

11.7 The team has security back-up & Institute for Clinical Evaluative Sciences (ICES) Privacy Policy.

30

Standard Evidence

confidentiality systems in place for the stroke data to meet legislation for protecting privacy & integrity of information.

Data is collected in accordance with the Data Sharing Agreement between Lakeridge Health and Institute for Clinical Evaluative Sciences

Lakeridge Health Privacy Advisory must be accepted prior to accessing Meditech

Lakeridge Health Statement of Confidentiality is signed upon employment

Lakeridge Health Colleague Commitment was completed in uLearn by Lakeridge Health Staff prior to September 30th, 2015. The purpose of the in module is to provide an overview of the following key policies and programs that we have in place to help create and maintain a healthy workplace at Lakeridge Health. Modules included; Respectful Workplace Policies, Privacy and Confidentiality; Accessibility and Patient Declaration of Values

Lakeridge Health Record Retention and Destruction Policy and Procedures

Health Information Management adhere to privacy regulations as outlined by the Information and Privacy Commissioner Data quality assurance processes are in place to ensure quality coding practices (i.e. Data Sources Manual for CIHI 340 & Special Project 740: A District Stroke Centre Initiative to Support Accuracy of Stroke Performance Measures Data)

31

Standard Evidence

Monitoring Quality and Achieving Positive Outcomes

12.0 The rehabilitation team uses data to monitor quality and achieve positive outcomes for inpatient stroke rehabilitation:

12.1 The inpatient stroke rehabilitation team accesses & reviews clinical & service utilization data.


Lakeridge Health Program Scorecards (Emergency Department, Critical Care and Post-Acute Specialty Services) include stroke specific metrics

Stroke Prevention Clinic Performance Metrics

Integrated Stroke Unit Quality Improvement board

12.2 The team identifies & monitors standardized process & outcome performance indicators for inpatient stroke rehabilitation services.


Lakeridge Health Program Scorecards (Emergency Department, Critical Care and Post-Acute Specialty Services) include stroke specific metrics

Continuous Quality Improvement Boards located in Emergency Department, Integrated Stroke Unit, Diagnostic Imaging and the Stroke Prevention Clinic

12.3 The team develops action plans for indicators that have not met performance thresholds.

As per Accreditation Canada action plans are required for ongoing indicator submissions. For example, if in follow up submissions for indicators, only 2/4 rehab indicators were met then you would have to submit an action plan for one of the 2 unmet indicators. For the onsite survey, distinction is achieved at onsite survey by meeting the thresholds for the minimum number of indicators (e.g. 7 of 9 acute core indicators)

12.4 The team monitors client and family Patient and Family Satisfaction Survey Surveys being completed

32

Standard Evidence

perspectives on the quality of inpatient stroke services.

on iPads prior to discharge from Integrated Stroke Unit and Stroke Prevention Clinic

12.5 The team compares its results on performance indicators with other similar interventions, programs or organizations.

Ontario Stroke Report Card

Ontario Stroke Network Central East Local Health Integration Network Report Card

Participation in Central East Stroke Network Steering Committee

12.6 The team uses information it collects about the quality of services to identify successes and opportunities for improvement & makes improvements in a timely way.

Stroke Navigation Line calls utilized to determine process improvement opportunities

iPad patient/family satisfaction surveys completed on the Integrated Stroke Unit and in the Stroke Prevention Clinic

Huddles (Emergency Department) and Daily Rounding used to monitor for immediate process improvement

Stroke Distinction Metrics Working Group bring monthly updates to the Stroke Distinction Sub-Committee

Lakeridge Health Stroke Distinction Score Card and Quality Based Funding Metrics, and Lakeridge Health Program Scorecards data is monitored, trended and used to identify areas of improvement

12.7 The team shares evaluation results with staff, clients & families.

Information is posted on Continuous Quality Improvement Boards Emergency Department, Critical Care and Integrated Stroke Unit

Ontario Stroke Network and Central East Local Health Integration Network Report Cards are posted on the Lakeridge Health intranet and presented annually to the Durham District Stroke Council

Tracer Template v. July 17 2015

Tracer Overview 1. Check in with area leadership 2. Review patient chart 3. Observation 4. Talk to staff/patient 5. Huddle with staff 6. Scan and send tracer documentation

Date: Tracer area: Area Leadership: Tracer Team Members: Summary of Strengths: Summary of Opportunities:

Question Possible Response Strength Opportunity Comments

Lead

ersh

ip

Tell me about the typical patients that you see here.

population served

Tell me something that your team is really great at.

What are you working on improving in your area?

Unit goals

Char

t Rev

iew

Is the Transfer of Accountability (TOA) form on the chart? (if applicable)

Yes or no

Is there consent for treatment on the chart? (if applicable)

Yes or no

Is there a care pathway or an order set on the chart?

Yes or no

Obs

erva

tion

Is appropriate hand hygiene observed? Yes or no

Is there patient education material related to stroke/TIA available?

Yes or no

Is all of the staff wearing ID badges? Yes or no

Staf

f Dis

cuss

ion

Guide me through the process of how a patient is admitted to your area

Transfer of accountability

How do know if it is safe to allow a new stroke/TIA patient to eat or drink? Review the documentation

TORBSST assessment

How do you assess your patients risk for falls? Review the documentation

Morse scale

How often do you assess patients for skin breakdown/pressure ulcer risk? Review the documentation

Braden scale

Tracer Template v. July 17 2015


Patie

nt In

terv

iew

Tell me about when you arrived at the hospital

Did anyone talk to you about what to expect while you are here in the hospital?

Involved in plan of care

Do you feel involved in your care or making decisions about your care?

Involved in plan of care

If you had a question or problem here who would you talk to?

Staff available to support

Teaching patients about strokes is really important. What kind of teaching have you been provided?

Patient education

Have you been given any education materials for stroke?

Patient education

Did you find it helpful? Patient education

** What is important to you while you are in the hospital?

** Can you tell me about something that we are doing really well?

** Is there something that we can improve on?


Gro

up S

taff

Disc

ussi

on

What training or sessions have you attended about stroke in the last year? Where do you track this?

uLEARN

What education do you provide to patients about stroke? Can you show me an example?

Documentation in Meditech, Resources on the unit, Patient education packages , Stroke education class

What specific stroke assessments do you perform on your patients?

TORBSST, PQH-P, CNS, SADQ, MOCA, Alpha-FIM, FIM, MMSE, CMSA.

Tell me about the ways that your team communicates about a patient?

TOA, documentation, patient rounds, DSM, physician communication board, charge nurse board, white board

Tracer Template v. Aug 12 2015

Date: Tracer area: Stroke Distinction – CT at LHO Area Leadership: Tracer Team Members: Summary of Strengths:

Summary of Opportunities:


Staf

f Dis

cuss

ion

This Tracer is focused on the CT departments role during a Code Stroke in preparation for the Stroke Distinction Accreditation survey in October 2015

Tell me about the process for a CT during a Code Stroke • CT-A stat ordered• Form faxed• CT tech paged• CT tech notifies on-call RadiologistWhy is the timing of the CT scan important during a Code Stroke? • Time is brainWhat is the target time for the CT scan • Door to CT Scan = 25 min or lessTell me what you do if there are patients already in the CT rooms How do you communicate the results back to the ED team • Radiologist pages Stroke MD & provides verbal reportWhat would you do if the CT machine was not working at LHO? • Transfer to LHBWhat do you think works well for your department during a Code Stroke? What do you think needs to improve?

What do you think could be done today to improve the Code Stroke process? Tell me something that your team is really great at.

Excellence – every moment, every day | www.lakeridgehealth.on.ca

Acute Stroke Protocol Memo (For Quality Improvement Processes Only)

Date:

To: CC:

From: Amy Maebrae-Waller (District Stroke Coordinator) ______________________________________________________

This memo is to provide you with feedback requiring the care of a ** year-old **ale that was seen in the LHO ED on *** for stroke thrombolysis.

The District Stroke Program reviews all Alteplase administrations and analyses all factors that contribute to timely treatment in order to achieve the provincial benchmark of a door to

needle time of 60 minutes.

Element Time Benchmark Achievement

Symptom Onset

Triage Time

Seen by ED Physician 10 minutes

Door to CT 25 minutes

Door to Needle 60 minutes

Door to Monitored Bed 180 minutes *Time as documented in the chart on paper or electronically*

Factors that may have contributed to the delay in door to needle time:

☐Time to ED Physician ☐Time to Stroke Physician

☐Medical Interventions ☐Diagnostic Results/Completion

☐Other:

Thank you for your participation in this patient’s care. We look forward to your feedback in order to improve the care of these patients and to resolve any issues that may arise.

Sincerely,

Amy Maebrae-Waller (District Stroke Coordinator)


Acute Stroke Protocol Memo

(For Quality Improvement Processes Only) Date:

To: CC:

From: Amy Maebrae-Waller (District Stroke Coordinator) _______________________________________________________

This memo is to provide you with feedback requiring the care of a __ year-old __male that was seen in the LHO ED on _________, 2015 for stroke thrombolysis.

The District Stroke Program reviews all Alteplase administrations and analyses all factors that contribute to timely treatment in order to achieve the provincial benchmark of a door to

needle time of 60 minutes.

Element Time Benchmark Achievement

Symptom Onset

Triage Time

Seen by ED Physician 10 minutes

Door to CT 25 minutes

Door to Needle 60 minutes

Door to Monitored Bed 180 minutes *Time as documented in the chart on paper or electronically*

Congratulations, this patient received Alteplase (tPA) in accordance with the Provincial Benchmarks for thrombolytic therapy for an ischemic stroke.

We recognize that this timeline can be challenging and appreciate everyone’s efforts to ensure the highest standard of patient care.

Thank you for your participation in this patient’s care. We look forward to your feedback in

order to improve the care of these patients and to resolve any issues that may arise.

Please do not hesitate to send your comments and suggestions to [email protected]

Sincerely,


mailto:[email protected]


In-House Stroke Protocol Memo

(For Quality Improvement Processes Only) Date:

To: CC:

From: Amy Maebrae-Waller (District Stroke Coordinator) ______________________________________________________

This memo is to provide you with feedback requiring the care of an ** year-old **ale that was seen as an In-House Code Stroke (**) on **** for stroke thrombolysis.

The District Stroke Program reviews all Alteplase administrations and analyses all factors that contribute to timely treatment.

Element Time

Symptom Onset

CT Time

Needle Time *Time as documented in the chart on paper or electronically*

Factors that may have contributed to the delay in the patient receiving tPA: ☐Time to Stroke Physician ☐Medical Interventions

☐Diagnostic Results/Completion

☐Other:

Thank you for your participation in this patient’s care. We look forward to your feedback in order to improve the care of these patients and to resolve any issues that may arise. If you feel that your staff would benefit from a debrief or review of the In-House Code Stroke

procedure please feel free to contact me.

Additionally, please do not hesitate to send your comments and suggestions to [email protected]

Sincerely,


mailto:[email protected]

Introducing the

Code Stroke Box As part of our process improvement strategies to help further improve our Door

to Needle Time for our Code Strokes the District Stroke Centre, ED and CrCu

have developed a Code Stroke Box.

The Code Stroke Box will be brought to Code Strokes and In-House Code Strokes

by the Nursing staff. The Code Stroke Box contains all the necessary documents

for a Code Stroke, including the Alteplase Order Sets, NIHSS Scales, Telestroke

Information, tPA Education Sheets for patients/families and the TOR-BSST® and

CNS forms.

If you require any additional information please contact

Sherry Campbell x3206 Allyson Eadie x5001

Katrina Manning x4533

Data Sources Manual for CIHI 340 & Special

Project 740 A District Stroke Centre Initiative to Support Accuracy of Stroke Performance

Measures Data Collection

(V4 May 2015)

Data Sources Manual for CIHI 340 & Special Project 740

Evidence-Based Stroke Performance Measures 1

Data Sources Manual

for CIHI 340 & Special

Project 740 A District Stroke Centre Initiative to Support Accuracy of

Stroke Performance Measures Data Collection

Evidence-Based Stroke Performance Measures Stroke Symptom Onset Date and Time

CT Scan/MRI Scan within 24 Hours of Hospital Arrival

Stroke Unit Admission

Administration of Acute Thrombolytic Therapy

Prescription for Antithrombotic Medication at Discharge

Dysphagia Screening (TOR-BSST)

Alpha-FIM Functional Assessment on Day Three of Admission

Referral to Stroke Prevention Services at ED Discharge

Purpose

The following

document outlines the

sources for data

abstraction to complete

the required fields of

CIHI 340 & Special

Project 740 in

preparation for Stroke

Quality Base

Procedures and Stroke

Distinction. This

document outlines the

sources of information

in order of priority in an

effort to increase the

accuracy of information

collected as there may

be minor discrepancies

in charting both

manually and

electronically.

Whenever possible,

record the data from

Source #1 first then

proceed to Source #2

and Source #3 if

needed.


2

Stroke Symptoms Onset Date and Time (Field 13-17 DAD, Field 92-96 NACRS)

Stroke symptoms onset is when the patient first started to experience stroke symptoms regardless of the

physical location of the patient at the time. This information is often referred to in the charting as the patient’s

Last Seen Normal (LSN) time or onset. At Lakeridge Health dates and times in the electronic documentation are

recorded as follows:

Date: DD/MM/YYYY Time: HHMM (24 hour clock)

Note The LSN time can be found in the Narrative section of the nurse’s notes in the electronic Emergency Triage

Record (Source 1) found under Emergency Department Database. In the rare circumstance that stroke


3

symptoms onset is not recorded on the triage record, it may be hand written on the Emergency Department

Assessment Record (Source 2).

Source 1 – Emergency Triage Record


4

Source 2 – Emergency Department Assessment Record (Front Page)

CT Scan/MRI Scan Completed within 24 Hours of Hospital Admission (Field 0.1 DAD, Field 80 NACRS)

Please Circle One Yes- if there is documentation that the patient received a CT or MRI scan within 24 hours of arrival at

Lakeridge Health Oshawa, Bomanville or from another acute care facility if the patient was transferred.

No- if there is no documentation that the patient received a CT or MRI scan within 24 hours of arrival

to Lakeridge Health Oshawa, Bomanville or from another acute acre facility if the patient was

transferred.

P (Prior) – if there is documentation that the patient received a prior CT or MRI scan at another acute

care facility other than at Lakeridge Health.

Note It is important to record the earliest diagnostic scan located electronically under

Imaging/Cardiopulmonary/EEG Reports (Source 1) of CT Head for Alteplase, CT Head with or without

contrast or MR-Head with or without contrast. It is best to record the time captured in Centricity on

the scan images. The time recorded on the Diagnostic Imaging Report (Source 3) may be inaccurate as


5

it is often the time the test is ordered or reported. The Diagnostic Imaging Report should only be used

in the case where Source 1 is not possible to obtain. The scan time should be compared against the

triage time located on the electronic Emergency Triage Record (see page 3 Source 2) to determine if 24

hours has elapsed. To verify if a patient has had a CT or MRI scan done at another acute care facility

look under the electronic OnBase Chart View under the tab diagnostics (Source 2).

Source 1 – Imaging/Cardiopulmonary/ EEG Reports (View Centricity imaging for the most accurate time)

Source 2 - Diagnostic Imaging Report


Stroke Unit Admission 6

Stroke Unit Admission (Field 0.2 DAD)

Please Circle One Yes – if there is documentation that the patient was admitted directly to the Integrated Stroke Unit or

was transferred to the Integrated Stroke Unit after admission regardless of the duration of stay on the

stroke unit.

No – There is no documentation in the chart that the patient was admitted directly to the Integrated

Stroke Unit or there is no documentation confirming the patient was admitted to the Integrated Stroke

Unit at any time during the hospitalization.

Note Integrated Stroke Unit admission information can be found electronically in the patient’s Visit History

under Abstract (Source 1). The Integrated Stroke Unit is located in the hospital on OC5.

Source 1 – Visit History Abstract

Administration of Acute Thrombolytic Therapy (Field 0.4-11 DAD, Field 82-90)

Please Circle One Yes – if there is documentation that the patient was administered acute thrombolysis medication in

the Emergency Department after arrival at Lakeridge Health, Oshawa.


Administration of Acute Thrombolytic Therapy 7

No – if there is no documentation that the patient was administered acute thrombolysis medication in

the Emergency Department after arrival at Lakeridge Health, Oshawa.

8 - if there is a diagnosis of hemorrhagic stroke (codes 160-161 of the DAD Abstracting Manual)

Note Acute thrombolysis will be documented as an intravenous medication. Normally, two medication times

are documented. The first medication administration time is a bolus dose. The bolus dose time is the

one that should be recorded into CIHI 340. The second administration time is when the IV medication

was started to run over 1 hour. The thrombolytic administration time can be found on the Emergency

Department Assessment Record (Source 1) under the section for medication administration. The time

may also be documented in the narrative of the Health Team Progress Notes section of the same form.

Another place the Alteplase time may be recorded is on the side of the initial order Source 2. Names

for acute thrombolytic therapy include tPA, rtPA, recombinant tissue plasminogen activator, tissue

plasminogen activator, or Alteplase. If you are unable to locate the time in either Source 1 or 2, it may

also be recorded on the Ischemic Stroke Alteplase Pre Printed Order set (Source 2).

Source 1- Emergency Department Assessment Record (reverse side)


8

Source 2- Ischemic Stroke Alteplase Pre Printed Orders (page 4)


Prescription for Antithrombotic Medication at Discharge 9

Prescription for Antithrombotic Medication at Discharge (Field 12 DAD, Field 91 NACRS)

Please Circle One Yes – there is documentation that the patient was given a prescription for antithrombotic medication

at discharge or if the patient was already on antithrombotic medication on admission (e.g. Aspirin) and

changed prescription to another antithrombotic on discharge (e.g. Aggrenox).

No – there is no documentation in the chart that the patient was given a prescription for

antithrombotic medication at discharge or if antithrombotic medications are not listed as a part of the

discharge medication.

8 – Not applicable in the case of hemorrhagic stroke (codes 160-161 of the DAD Abstracting Manual);

record 8 if the patient dies during the inpatient admission.

9 – Unknown; record if discharge notes and the discharge medication lists are unavailable.

Note This information can be collected from the Discharge Instruction Record (Inpatients) provided to the

patient at the time of discharge (Source 1). Additional sources for patient medications during the

hospitalization can be found electronically under Current Medication Orders (Source 2) or Medication

Order History (Source 3) or Patient Care Notes - Pharmacist (Source 4). For patients that were seen in

the Emergency Department but not admitted to hospital documentation may be found on the ED

Prescription Record (Source 5), ER Record (Source 6) or Stroke Prevention Clinic Referral (Source 7).

Source 1- Discharge Instruction Record


Note 10

Source 2 – Current Medication Orders

Source 3 – Medication Orders History


Note 11

Source 4 – Patient Care Notes- Pharmacist

Source 5 – ED Prescription (ED Patients Only)


Note 12

Source 5 – ER Record (ED Patients)

Source 6 – Stroke Prevention Clinic Referral


13

Antithrombotic Medication included in CIHI 340:

Anticoagulants Antiplatlets

Warfarin – Coumadin® Acetylsalicylic Acid (ASA) - Aspirin®

Rivaroxaban - Xarelto® Clopidogrel - Plavix®

Dabigatran - Pradaxa® ASA/Dipyridamole - Aggrenox®

Apixaban - Eliquis® Dipyridamole - Persantine®

Fondaparinux - Arixtra® Prasugrel - Effient®

Danaparoid - Orgaran® Ticlopidine - Ticlid®

Heparin Ticagrelor - Brilinta®

Dalteparin - Fragmin® Pentoxifylline - Trental®

Enoxaparin - Lovenox® Anagrelide - Agrylin®

Tinzaparin - Innohep®

Nadroparin - Fraxiparine®

Dysphagia Screening (Open Field)

Please Circle One Yes – if there is documentation that a swallowing screening has be completed on the patient by either

a Speech Language Pathologist or a TOR-BSST Screener.

No – if there is no documentation that a swallowing screening has been completed on the patient by

either a Speech Language Pathologist or a TOR-BSST Screener.

Note At Lakeridge Health the screening tool used for Dysphagia is called the Toronto Bedside Swallowing

Screening Test (TOR-BSST). This screening is different than a Speech Language Pathologist (SLP)

assessment. TOR-BSST screening documentation is recorded in two places; on a yellow paper copy in

the patients chart (Source 1) or electronically under assessments (Source 2); both sources are equally

accurate. Source 1 is commonly used in the Emergency Department whereas Source 2 is often used for

admitted patients.


Dysphagia Screening 14

Source 1 – TOR-BSST Screening Sheet (Front Page)


15

Source 2 – Assessment Forms Summary, Stroke: TOR-BSST

Alpha-FIM® Functional Assessment (Special Project 740, Group 16, Fields 01-18, DAD)

In Ontario, Special Project 740 is mandatory for all applicable DAD abstracts with discharges dates of

on or after October 2014. Special Project 740 is to be coded on the DAD abstract for all acute inpatient

admissions with a new ischemic and/or hemorrhagic stroke (See page 1 of this document for inclusion

and exclusion criteria for Special Project 340 vs. Special Project 740).

There are 4 data elements to be collected under Special Project 740 (Group 16, Field 18). The data

elements to be collected include:

1. Group 16, Field 01: Documentation of Alpha FIM® Scores 2. Group 16, Fields 02-09: Alpha FIM® Completion Date 3. Group 16, Fields 10-11: Projected FIM® Raw Motor Rating 4. Group 16, Fields 12-13: Projected FIM® Raw Cognitive Rating


Alpha-FIM® Functional Assessment 16

Note Alpha-FIM® is a functional assessment that is completed on stroke patients admitted to Lakeridge

Health on day three of admission. The Alpha FIM® may be repeated throughout the patient’s length of

stay however data for the first assessment should be recorded. The information can be found

electronically under Assessment Forms then Alpha FIM Asmt & Results (Source 1). This is the only

source where the data is consistently collected.

Source 1 – Assessment Form Summary, Alpha FIM Asmt & Results

Project 740 AlphaFIM® (Group 16, Fields 01–18)

740 A Y Y Y Y M M D D S S C C

18 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17

AlphaFIM®

Completion

Date

Projected

FIM®-13

Raw Motor

Rating

Projected

FIM®-5 Raw

Cognitive

Rating Documentation

of AlphaFIM®

Project

Number


17

Referral to Stroke Prevention Services at ED Discharge (Field 81 NACRS)

Please Circle One Yes – if there is documentation in the chart that a referral was made for the patient to stroke

prevention services prior to leaving the Emergency Department.

No – if no appointment was made and there is no documentation that confirms the patient was given a

referral for stroke prevention services.

Note Referral to Stroke Prevention Services at ED Discharge captures whether patients with a diagnosis of

stroke or transient ischemic attack are discharged back to the community directly from the ED with a

referral for stroke prevention follow-up.

Stroke prevention services may include referrals made to any of the following: Stroke Prevention Clinic,

Cardiovascular Clinic, Vascular Clinic, Cardiac Clinic, Atherosclerosis Clinic, Neurology Clinic, Neurologist

or General Internist.

This referral information can be found on the ER Record (Source 1) under the All Documents tab in

OnBase Chart View or on the Stroke Prevention Clinic Referral (Source 2). Additional locations include


Referral to Stroke Prevention Services at ED Discharge 18

the Doctor’s Order Sheet (Source 3) that is located in OnBase Chart View under the Provider’s Orders

tab or under the Referrals – Req’s tab (Source 4).

Source 1 – ER Record



Source 2 – Stroke Prevention Clinic Referral

Source 3 – Doctor’s Order Sheet

Source 4 – Referrals – Req’s (Sample 1) (Sample 2)



www.stroke.centraleasthealthline.caYour newest resource in stroke care.Learn more about the many services available to help people who have survived a stroke or those seeking stroke prevention.

Visit www.stroke.centraleasthealthline.ca to find one-stop information for Durham Region residents looking for trustworthy and up-to-date stroke information and resources.

© Heart And Stroke Foundation of Canada, 2014

LEARN THE SIGNS OF STROKE

Learn how to help yourself and your family so we can help you.Visit www.lakeridgehealth.on.ca and search ‘Stroke Care’ for additonal resources.