Stroke Education Q I Initiative–

BroMenn Healthcare

October 2007

BroMenn HealthcareNormal, Illinois

• BroMenn Regional Medical Center (BRMC)– 224 bed, full-service, teaching hospital – Level II trauma center with regional referral– Dedicated neuroscience unit– Inpatient rehabilitation

• Eureka Hospital (ECH)– 34 bed, critical access hospital

• Home Care & Hospice

Decision to Pursue Stroke Designation at BRMC

• To build on existing program strengths– Neuro, neurosurgical & neuro-

residency programs• Patient volume sufficient to support

a dedicated program– 200 strokes admitted annually– 100 TIAs admitted annually

Designation Objectives

• Promote a culture of interdisciplinary, patient-focused approach to stroke care across the care continuum

• Promote evidence-based practice• Maximize patient care outcomes• Continuous quality improvement

Collaborative Practice Team Was Formed

Neuroscience Care Unit

Intensive Care Unit

Other Nursing Unit Representation

Physical Medicine & Rehabilitation

Emergency Department

Case ManagementPharmacy, Lab & Nutritional Services

Cardiopulmonary Services

Emergency Medical System (EMS)

RadiologyPhysician Representation

American Heart/ Stroke Association

Practice Team

• Establishes the program’s care delivery model, goals & improvement priorities

• Researches and implements best practices

• Coordinates educational efforts• Monitors quality measure performance• Develops performance improvement plans• Includes interdisciplinary hospital,

medical staff and community representation

• Meets 4-6 times per year

Care Delivery Model Was Established

Patient experiences symptoms of

stroke

EMS is activated

Code Gray - Neurologist evaluation - NIHSS - Labs drawn - Imaging - TPA risk assessment

Location of the patient?

Is FAST Criteria met?

Nursing evaluationOutside

the Hospital

Within the

Hospital

Admission to ICU

TPA or Intervention?

Admission to NSCU

Ischemic Stroke/ TIA Care Map - Assessment guidelines - BP management - Swallow screen - Antithrombotics - Anticoagulation for afib - Lipid profiling - DVT prophylaxis - Patient education

Type of Stroke?

Admission to ICU

Evidence of hemorrhage

No evidence of hemorrhage

Yes

No

Neurosurgical evaluation and

additional imaging

Ischemic Stroke with Thrombolysis - Assessment guidelines - Bleeding precautions - BP management - Swallow screen - Antithrombotics - Anticoagulation for afib - Lipid profiling - DVT prophylaxis - Patient education

Intra-cerebral or sub-arachnoid hemorrhage

orders

Rehab evaluation

Discharge disposition determined - Rehabilitation - Skilled Care - Intermediate Care (Nursing Home Placement) - Home with Home Care - Home

Delivery of Stroke Care

Date: 12/05Rev: 09/06

Model developed from guidelines published by AHA, ASA and the Mayo Clinic.

Addresses screening performed in the community as well as the hospital

Includes diagnosis and care of ischemic and hemorrhagic strokes, and TIAs

The Model Encompasses

• FAST Screening• EMS protocols and education• Clinical practice guidelines to direct

patient care• Protocols for rapid diagnosis, BP

management, thrombolysis, education and prevention of complications

• Monitoring for early detection and response to problems

• Early establishment of rehabilitation plan

Benchmarking

Measure Q3 ‘04Q1 ’07(Januar

y)Target

IllinoisCaptur

eDVT Prophylaxis 64% 100% 100% 75%Antithrombotics at Discharge 89% 100% 100% 97%Anticoagulation for A Fib 100% 100% 100% 93%TPA Considered 67% 100% 100% 45%Antithrombotics w/in 48 Hrs 89% 94% 100% 91%Lipid Profile 33% 78% 90% 60%Screen for Dysphagia 47% 56% 100% 47%Stroke Education 14% 92% 90% 64%Smoking Cessation 17% 100% 90% 84%Plan for Rehab 70% 88% 90% 88%

Stroke Education

0%

20%

40%

60%

80%

100%

Q3-04 Q4-04 Q1-05 Q2-05 Q3-05 Q4-05 Q1-06 Q2-06 Q3-06 Q4-06 Q1-07

Work Group Meeting

Stroke Units

Marketing; Community Wellness

Leadership (QRM, Clin. ED)

Collaborative Culture

Stroke Binder

Let’s talk about Stroke

Progress

45%24%

14%0

20

40

60

80

100

3Q (2004) 4Q 1Q (2005) 2Q 3Q

Stroke Education

Stroke education workgroup

Development of patient education materials

Standardized Documentation

Measure

73%

14%

24%

71%

50%

0

20

40

60

80

100

3Q(2004)

4Q 1Q (2005)

2Q 3Q 4Q 1Q (2006)

Stroke Education

Standardized form for

documentation

More Staff

education

Ongoing Process

Measure

Plan

Act

CVA - TIA

• We do not use a separate CareMap for TIA patients.

• CVA patients were over the 90% mark, but TIA patients were not receiving the education.

Almost there

89%

14%

24%

71%

50%

0

20

40

60

80

100

3Q(2004)

4Q 1Q (2005)

2Q 3Q 4Q 1Q (2006)

2Q

Stroke Education Reinforcement to use with TIA

patients

Meditech Documentation

• Over the course of the last year on-line documentation had come full swing.

• We knew nurses were educating and the supply of notebooks correlated.

• Documentation needed to occur in the electronic realm.

Breaking the 90th !!

92%89%

14%

24%

71%

50%

020406080

100

3Q (2

004) 4Q

1Q (2

005) 2Q

3Q

4Q

1Q (2

006) 2Q

3Q 4Q

1Q (2

007)

Stroke Education

EMR documentation

developed

Holding the ground

Measure

Plan

Act

Questions

Contacts

Jeff Williams, Neuro Case Manager

jwilliams@bromenn.org309-268-3512