Quality of Care for Stroke Patients Jerilyn Alexander, RN Stroke Coordinator Trinity Health

Quality of Care for Stroke Patients

Jerilyn Alexander, RN Stroke Coordinator

Trinity Health

Quality

• Everyone wants it whether it is for your house, your car, or healthcare!

• Quality healthcare is a measurement of the healthcare received at your Dr.’s office, the ER, or during a hospital stay

• It goes beyond the manners and attitude of health care providers

Definition

• According to the Institute of Medicine it is defined as “the extent to which health services provided to individuals and patient populations improve desired health outcomes. The care should be based on the strongest clinical evidence and provided in a technically and culturally competent manner with good communication and shared decision making.”

Quality Improvement

• A formal approach to the analysis of performance and systematic efforts to improve it.

• Key word is Improvement• Always strive for the best outcome!

Stroke Care

• How do we get a sense of the quality?

• What’s the best way to care for stroke patients?

• Are there guidelines for care of a stroke patients?

Stroke Care

• Guidelines:o 2007 AHA/ASA Guidelines for the Early

Management of Adults with Ischemic Strokeo 2011 Revised and Updated Recommendations for

the Establishment of Primary Stroke Centerso 2009 Comprehensive Overview of Nursing and

Interdisciplinary Care of the Acute Stroke patient: A Scientific Statement from the American Heart Association

Stroke Care

• The guidelines are the basis for protocols for treating the Acute Stroke Patient

• Drive the Quality care of stroke patients• GWTG-Stroke helps healthcare facilities ensure

continuous quality improvement of stroke treatment by aligning clinical care with evidence-based guidelines.

• AHA/ASA have partnered with Joint Commission for certification of Primary Stroke Centers.

• Began the Certification Program in 2003.

Primary Stroke Center Certification

• BAC Recommendations– Establishing Criteria for emergency response– Availability of neuroimaging 24/7– Laboratory, Neurology, and Neurosurgery support– Administrative Support– Appropriate Staff Education– Outcomes tracking.

State of North Dakota

• Developing Statewide Stroke System of Care• Similar to State Trauma System• Encouraging all Tertiary Centers to become

Primary Stroke Centers• Sanford-Fargo and St. Alexius Bismarck are

currently only 2 certified but all centers are pursuing it.

Certification Requirements

• Use standardized method of delivering care based on BAC recommendations for establishment of primary stroke centers

• Support a patient’s self management activities• Tailor treatment and intervention to individual needs• Promote the flow of patient information across settings and

provides while protecting patient rights, security and privacy• Analyze and use standardized performance measure data to

continually improve treatment plans• Demonstrate their application of and compliance with the

clinical guidelines published by AHA/ASA or equivalent evidence-based guidelines.

Joint Commission Standardized Performance Measures for Stroke

• Venous Thromboembolism(VTE) Prophylaxis by Day 2 (Ischemic and Hemorrhagic)

• Discharged on Antithrombotic Therapy• Anticoagulation Therapy for At Fib/Flutter• Thrombolytic Therapy• Antithrombotic Therapy by end of Hospital Day 2• Discharged on Statin Medication• Stroke Education (Ischemic and Hemorrhagic)• Assessed for Rehab (Ischemic and Hemorrhagic)

Data

• Each measure needs to be analyzed and evaluated.

• Where does the information come from?• What is done with it?• Who is responsible for what?• How is it coordinated?

Data

• Each stroke patients care is reviewed on an ongoing basis

• Analyzed according to the standardized performance measures

• Improve upon care ongoing rather than retrospectively.

• Outcome Sciences database can benchmark to other facilities.

Stroke Quality

• 8 indicators for ischemic stroke patients and 3 of these same indicators are looked at for hemorrhagic stroke patients.

• GWTG looks at 9 indicators primarily looking at timeliness in the emergency phase of presentation.

• CMS looks at 3 different areas (Stroke, VTE, ED), with some overlap of the Joint Commission Indicators. For stroke they will look at 7 indicators.

Venous Thromboembolism Prophylaxis

• Thromboembolism is more common than we think• PE accounts for approx 10% of deaths after stroke• DVT and PE are more likely to occur in the first 3

months after stroke• Methods to prevent include early mobilization,

antithrombotic agents, and external compression devices

• If contraindicated may need Filter placement into the Inferior Vena Cava

Venous Thromboembolism Prophylaxis

• To meet the indicator:– Must be administered the day of admission or by

midnight the 2nd day– Lovenox or heparin and/or compression devices

acceptable– If no VTE warranted (ex. Patient ambulatory or low

risk of VTE) it needs to be documented in chart before midnight on the 2nd inpatient day

– Any reason for not meeting indicator needs to be documented in the chart (refusal, etc)

STK-1Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis

was given the day of or the dayafter hospital admission.

Time Period: Q1 2011 - Q4 2011; Site: Trinity Hospitals (52674)Data For: STK-1

Data For: STK-1Benchmark Group Time Period Numerator Denominator % of Patients

All ND Hospitals Q1 2011 109/125 87.2%All ND Hospitals Q2 2011 131/149 87.9%All ND Hospitals Q3 2011 128/156 82.1%All ND Hospitals Q4 2011 143/171 83.6%

Discharged on Antithrombotic Therapy

• Imperative for stroke prevention• There needs to be documentation in the chart

that patient was given prescription for antithrombotic medication at discharge

• Acceptable medications include ASA, Aggrenox, Plavix, Ticlid, Lovenox, Coumadin

• Low dose anticoagulant to prevent DVT’s are insufficient as antithrombotic therapy to prevent recurrent strokes

Discharged on Antithrombotic Therapy

• Antiplatelet or Anticoagulant are acceptable• If not prescribed, needs to be documented by

the physician.• Acceptable documentation:– Allergic– Refusal– Risk for or actual bleeding– Serious side effects– Terminal illness, comfort measures only

STK-2Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.

Time Period: Q1 2011 - Q4 2011



Anticoagulation Therapy for Atrial Fib/Flutter

• A patient that has a documented episode of Atrial Fib this admission. Remote history doesn’t matter.

• If patient has Atrial Fib or Flutter must go home on anticoagulant if not, needs to be documented.

• Acceptable documentation– Allergy– Mental status– Refusal– Risk of or actual bleeding– Risk for falls– Serious side effects to medication– Terminal illness/comfort measures only

STK-3Ischemic stroke patients with atrial fibrillation/flutter who are

prescribed anticoagulation therapy at hospital discharge.Time Period: Q1 2011 - Q4 2011



Thrombolytic Therapy

• If patient arrives within 2 hours of symptom onset, they should receive thrombolytics within 3 hours.

• If Ischemic Stroke Patient does not receive IV tPA, a documented reason needs to be included in the patient chart.

• May use exclusion criteria in addition to:– Advanced age– Care team cannot determine eligibility– Left heart thrombus– Life expectancy <1 year– NIHSS>22

STK-4Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known

well and for whom IV t-PA was initiated at this hospital within 3hours of time last known well.




Antithrombotic Therapy by end of Hospital Day 2

• Must be administered by midnight of Day 2• Antiplatelet (ASA, Aggrenox, Plavix, Ticlid) or

Anticoagulant (Heparin IV, Lovenox, Coumadin, or arixtra)

• Acceptable documented reasons for not meeting:– Risk of bleeding– Refusal– Terminal illness– Allergy– Serious side effect of medication

STK-5Ischemic stroke patients administered antithrombotic therapy by the

end of hospital day 2.Time Period: Q1 2011 - Q4 2011


All ND Hospitals Q1 2011 94/99 94.9%All ND Hospitals Q2 2011 108/116 93.1%All ND Hospitals Q3 2011 135/141 95.7%All ND Hospitals Q4 2011 135/ 40 96.4%

Discharged on Statin Medication

• The patient should be discharged on cholesterol reducing medication as part of prevention

• Acceptable documented reasons for not prescribing a statin on discharge– Allergy– Refusal– Arrhythmias– Hepatitis– Hypoglycemia– Liver failure– Rectal Hemorrhage – Intracranial Hemorrhage– Rhabdomyolosis

STK-6Ischemic stroke patients with LDL >= 100 mg/dL, or LDL not measured, or, who were on a lipid-lowering

medication prior to hospital arrival are prescribedstatin medication at hospital discharge.




Stroke Education

• Required documentation for education– Personal modifiable risk factors for stroke– Stroke Warning Signs and Symptoms– How to Activate EMS for Stroke– Need for Follow up after Discharge– Medication information

Stroke Coordinator consult at Trinity, that alerts the need for education to patients with strokes or TIA’s.

STK-8Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital

stay addressing all of the following:activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk

factors for stroke, and warning signs andsymptoms of stroke.




Assessed for Rehab

• Assessment must be completed by any one member of the Rehab team including:– Physiatrist– Neuro-psychologist– Physical Therapist– Occupational Therapist– Speech Therapist

STK-10Ischemic or hemorrhagic stroke patients who were assessed for

rehabilitation services.Time Period: Q1 2011 - Q4 2011



Data Reports

• Once all the data is retrieved, entered into system, generates a report…now what??

• Look at indicators that are not improving, how can we fix it?

• Break it down, piece by piece.

STK-1 VTE Prophylaxis

Analysis

• Review each case, found that SCD’s were being ordered since it was a pre-checked order on standard stroke order set. This was done so that if Lovenox was not ordered they would at least meet indicator with SCD’s

• Nursing was not placing SCD’s on the patient or not documenting it in the HER.

STK 1-Compliance Action Plan

• December 2011-Worked with Informatics to develop report that prints at each nurses station every shift, reporting which patients have orders for SCD’s or Foot pumps

• December 2011- Included quality indicators in in-services on Ischemic stroke to make nursing staff more aware

• January 2012-Worked with Clinical Nurse Educators on compliance with staff

• January 2012-Will have the SCD or Foot pump order fire a task for nursing to complete upon application of SCD’s or foot pumps. Going to Profession Practice Committee in February 2012.

Follow up

• This continues to be a work in progress• Follow up with staff, physicians with the

corrective plan of action.• Frequent updates to Clinical Educators if

compliance drops off.

GWTG Stroke Measures

• Door to MD evaluation-10 Minutes• Door to CT Scan-25 minutes• Door to CT Scan Interpretation-45 minutes• Door to EKG-45 minutes• Door to Lab Results-45 minutes• Door to IV tPA-60 minutes• Door to CXR-45 minutes• Door to admission-3 hours

Stroke Treatment

Action Plan

• Instituted Stroke Alert for patients that present with symptom onset less than 8 hours.

• Mobilizes a team to respond and alerts the Neurologist of potential stroke patient

• Once that was in place for several months began to break down the process and look at the data

%Door To CT <= 25minPercent of patients who receive brain imaging within 25 minutes of arrival


Data For: %Door To CT <= 25minBenchmark Group Time Period Numerator Denominator % of Patients

My Hospital Q1 2011 10.0%My Hospital Q2 2011 22.5%My Hospital Q3 2011 9.7%My Hospital Q4 2011 17.1%All Hospitals Q1 2011 24.7%All Hospitals Q2 2011 24.8%All Hospitals Q3 2011 24.8%All Hospitals Q4 2011 24.9%

Quality issues

• Break down the process, why is it taking so long?• Nursing delay (IV placement, assessment)?• Lab delay (Delay due to drawing blood taking too

long)?• EKG delay• Radiology (Delay in transport, logistics of

transport, delay in staff coming to the ETC)?• What % of our patients are getting CT in 25

minutes?

Action Plan

• New PI Process form for timing of stroke alerts• Educate staff on new form• Review process of assessment with Nursing

staff in the ETC• Continue to work with Radiology regarding

timeliness of CT scan results.• Continue to follow up with involved

departments

Meaningful Use

Meaningful Use is using certified EHR technology to• Improve quality, safety, efficiency, and reduce health

disparities• Engage patients and families in their health care• Improve care coordination• Improve public health• All the while maintaining privacy and security

Meaningful Use mandated in law to receive incentives

What are the Three Main Components of Meaningful Use?

The Recovery Act specifies the following 3 components of Meaningful Use:1. Use of certified EHR in a meaningful manner (e.g.,

e-prescribing)2. Use of certified EHR technology for electronic

exchange of health information to improve quality of health care

3. Use of certified EHR technology to submit clinical quality measures(CQM) and other such measures selected by the Secretary

“Core measures”

• Core measure program is completely separate from the Meaningful Use Quality Reporting Program

• Core measure data elements are captured manually from patients final bill

• E-measures are captured electronically• Core measure definitions come from a list that

the abstractor chooses from (ICD-9 codes)• Meaningful use measures come from SNOMED

How to comply

• Will software be able to pull this data and be Meaningful Use compatible?

• Will elements need to be built into the system to retrieve this data?

MU: Clinical Quality MeasuresEligible Hospitals and CAHs must complete all 15:

1. Emergency Department Throughput –admitted patients Median time from ED arrival to ED departure for admitted patients

2. Emergency Department Throughput –admitted patients –Admission decision time to ED departure time for admitted patients3. Ischemic stroke –Discharge on anti-thrombotics4. Ischemic stroke –Anticoagulation for A-fib/flutter5. Ischemic stroke –Thrombolytic therapy for patients arriving within 2 hours of symptom onset6. Ischemic or hemorrhagic stroke –Antithrombotic therapy by day 27. Ischemic stroke –Discharge on statins8. Ischemic or hemorrhagic stroke –Stroke education9. Ischemic or hemorrhagic stroke –Rehabilitation assessment10. VTE prophylaxis within 24 hours of arrival11. Intensive Care Unit VTE prophylaxis12. Anticoagulation overlap therapy13. Platelet monitoring on unfractionated heparin14. VTE discharge instructions15. Incidence of potentially preventable VTE

CMS Stroke Indicators

• Discharged on Antithrombotic• Anticoagulation Therapy for At Fib/Flutter• Thrombolytic Therapy within 3 hours if patient

arrives within 2 hours• Antithrombotic Therapy by end of Hospital Day 2• Discharged on Statin Medication• Stroke Education (Ischemic and Hemorrhagic)• Assessed for Rehab (Ischemic and Hemorrhagic)

The Challenge• EHR Compliance• Quality measure specifications and logic must be clearly defined

and unambiguous to support automated analysis and reporting of quality measurement data. Instructions like these are difficult to implement in an electronic system due to the number of potential scenarios and corresponding logic that need to be specified

• Each organization should understand how data requirements will be captured in their local EHR system to ensure exclusionary criteria are applied appropriately and denominator results are calculated and reported correctly.

Kallem, Crystal. "Analyzing Clinical Quality Measures for Meaningful Use." Journal of AHIMA 81, no.11 (November/December 2010): 56-59.

Any Questions?

References• http://www.ncbi.nlm.nih.gov/books/NBK2681/• http://www.jointcommission.org/

specifications_manual_for_national_hospital_inpatient_quality_measures/

• https://qi.outcome.com/• http://www.heart.org/HEARTORG/HealthcareResearch/

GetWithTheGuidelinesHFStroke/Get-With-The-Guidelines-Stroke-Home-Page_UCM_306098_SubHomePage.jsp

• Activase.com• https://www.cms.gov/EHRIncentivePrograms/Downloads/

MU_Stage1_ReqOverview.pdf• http://thomsonreuters.com/content/healthcare/pdf/collateral/

clin_perform_improvement_0211• Kallem, Crystal. "Analyzing Clinical Quality Measures for Meaningful

Use." Journal of AHIMA 81, no.11 (November/December 2010): 56-59.

https://qi.outcome.com/



Documents

Quality of Care for Stroke Patients Jerilyn Alexander, RN Stroke Coordinator Trinity Health