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

2. 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

3. 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.”

4. 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!

5. 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?

6. Stroke Care Guidelines:
2007 AHA/ASA Guidelines for the Early Management of Adults with Ischemic Stroke
2011 Revised and Updated Recommendations for the Establishment of Primary Stroke Centers
2009 Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Stroke patient: A Scientific Statement from the American Heart Association

7. 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.

8. 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.

9. 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.

10. 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.

11. 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)

12. 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?

13. 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.

14. 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.

15. 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

16. 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)

17. after hospital admission.
STK-1
Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day
after hospital admission.
Time Period: Q Q4 2011; Site: Trinity Hospitals (52674)
Data For: STK-1
Data For: STK-1
Benchmark Group Time Period Numerator Denominator % of Patients
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %

18. 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

19. 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

20. Benchmark Group Time Period Numerator Denominator % of Patients
STK-2
Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.
Time Period: Q Q4 2011
Data For: STK-2
Benchmark Group Time Period Numerator Denominator % of Patients
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %

21. 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

22. Benchmark Group Time Period Numerator Denominator % of Patients
STK-3
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge.
Time Period: Q Q4 2011
Data For: STK-3
Benchmark Group Time Period Numerator Denominator % of Patients
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %

23. 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

24. hours of time last known well. Time Period: Q1 2011 - Q4 2011
Acute 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 3
hours of time last known well.
Time Period: Q Q4 2011
Data For: STK-4
Benchmark Group Time Period Numerator Denominator % of Patients
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %

25. 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

26. Benchmark Group Time Period Numerator Denominator % of Patients
STK-5
Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2.
Time Period: Q Q4 2011
Data For: STK-5
Benchmark Group Time Period Numerator Denominator % of Patients
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %

27. 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

28. statin medication at hospital discharge.
STK-6
Ischemic stroke patients with LDL >= 100 mg/dL, or LDL not measured, or, who were on a lipid-lowering medication prior to hospital arrival are prescribed
statin medication at hospital discharge.
Time Period: Q Q4 2011
Data For: STK-6
Benchmark Group Time Period Numerator Denominator % of Patients
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %

29. 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.

30. Benchmark Group Time Period Numerator Denominator % of Patients
STK-8
Ischemic 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 and
symptoms of stroke.
Time Period: Q Q4 2011
Data For: STK-8
Benchmark Group Time Period Numerator Denominator % of Patients
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %

31. 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

32. Benchmark Group Time Period Numerator Denominator % of Patients
STK-10
Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services.
Time Period: Q Q4 2011
Data For: STK-10
Benchmark Group Time Period Numerator Denominator % of Patients
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %
All ND Hospitals Q / %

33. 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.

34. STK-1 VTE Prophylaxis

35. 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.

36. 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 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.

37. 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.

38. 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

39. Stroke Treatment

40. 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

41. %Door To CT <= 25min
Percent of patients who receive brain imaging within 25 minutes of arrival
Time Period: Q Q4 2011
Data For: %Door To CT <= 25min
Benchmark Group Time Period Numerator Denominator % of Patients
My Hospital Q %
My Hospital Q %
My Hospital Q %
My Hospital Q %
All Hospitals Q %
All Hospitals Q %
All Hospitals Q %
All Hospitals Q %

42. 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?

43. 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

44. Meaningful Use mandated in law to receive incentives
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

45. What are the Three Main Components of Meaningful Use?
The Recovery Act specifies the following 3 components of Meaningful Use:
Use of certified EHR in a meaningful manner (e.g., e-prescribing)
Use of certified EHR technology for electronic exchange of health information to improve quality of health care
Use of certified EHR technology to submit clinical quality measures(CQM) and other such measures selected by the Secretary

46. “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

47. 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?

49. MU: Clinical Quality Measures
Eligible Hospitals and CAHs must complete all 15:
Emergency Department Throughput –admitted patients Median time from ED arrival to ED departure for admitted patients
Emergency Department Throughput –admitted patients –Admission decision time to ED departure time for admitted patients
Ischemic stroke –Discharge on anti-thrombotics
Ischemic stroke –Anticoagulation for A-fib/flutter
Ischemic stroke –Thrombolytic therapy for patients arriving within 2 hours of symptom onset
Ischemic or hemorrhagic stroke –Antithrombotic therapy by day 2
Ischemic stroke –Discharge on statins
Ischemic or hemorrhagic stroke –Stroke education
Ischemic or hemorrhagic stroke –Rehabilitation assessment
10. VTE prophylaxis within 24 hours of arrival
Intensive Care Unit VTE prophylaxis
Anticoagulation overlap therapy
Platelet monitoring on unfractionated heparin
VTE discharge instructions
Incidence of potentially preventable VTE

50. 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)

52. 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):

53. Any Questions?

54. References http://www.ncbi.nlm.nih.gov/books/NBK2681/
Activase.com
Kallem, Crystal. "Analyzing Clinical Quality Measures for Meaningful Use." Journal of AHIMA 81, no.11 (November/December 2010):