Presentation on theme: "Quality of Care for Stroke Patients"— Presentation transcript:
1Quality of Care for Stroke Patients Jerilyn Alexander, RNStroke CoordinatorTrinity Health
2QualityEveryone 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 stayIt goes beyond the manners and attitude of health care providers
3DefinitionAccording 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.”
4Quality ImprovementA formal approach to the analysis of performance and systematic efforts to improve it.Key word is ImprovementAlways strive for the best outcome!
5Stroke 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?
6Stroke Care Guidelines: 2007 AHA/ASA Guidelines for the Early Management of Adults with Ischemic Stroke2011 Revised and Updated Recommendations for the Establishment of Primary Stroke Centers2009 Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Stroke patient: A Scientific Statement from the American Heart Association
7Stroke CareThe guidelines are the basis for protocols for treating the Acute Stroke PatientDrive the Quality care of stroke patientsGWTG-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.
8Primary Stroke Center Certification BAC RecommendationsEstablishing Criteria for emergency responseAvailability of neuroimaging 24/7Laboratory, Neurology, and Neurosurgery supportAdministrative SupportAppropriate Staff EducationOutcomes tracking.
9State of North Dakota Developing Statewide Stroke System of Care Similar to State Trauma SystemEncouraging all Tertiary Centers to become Primary Stroke CentersSanford-Fargo and St. Alexius Bismarck are currently only 2 certified but all centers are pursuing it.
10Certification Requirements Use standardized method of delivering care based on BAC recommendations for establishment of primary stroke centersSupport a patient’s self management activitiesTailor treatment and intervention to individual needsPromote the flow of patient information across settings and provides while protecting patient rights, security and privacyAnalyze and use standardized performance measure data to continually improve treatment plansDemonstrate their application of and compliance with the clinical guidelines published by AHA/ASA or equivalent evidence-based guidelines.
11Joint Commission Standardized Performance Measures for Stroke Venous Thromboembolism(VTE) Prophylaxis by Day 2 (Ischemic and Hemorrhagic)Discharged on Antithrombotic TherapyAnticoagulation Therapy for At Fib/FlutterThrombolytic TherapyAntithrombotic Therapy by end of Hospital Day 2Discharged on Statin MedicationStroke Education (Ischemic and Hemorrhagic)Assessed for Rehab (Ischemic and Hemorrhagic)
12Data 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?
13Data Each stroke patients care is reviewed on an ongoing basis Analyzed according to the standardized performance measuresImprove upon care ongoing rather than retrospectively.Outcome Sciences database can benchmark to other facilities.
14Stroke Quality8 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.
15Venous Thromboembolism Prophylaxis Thromboembolism is more common than we thinkPE accounts for approx 10% of deaths after strokeDVT and PE are more likely to occur in the first 3 months after strokeMethods to prevent include early mobilization, antithrombotic agents, and external compression devicesIf contraindicated may need Filter placement into the Inferior Vena Cava
16Venous Thromboembolism Prophylaxis To meet the indicator:Must be administered the day of admission or by midnight the 2nd dayLovenox or heparin and/or compression devices acceptableIf no VTE warranted (ex. Patient ambulatory or low risk of VTE) it needs to be documented in chart before midnight on the 2nd inpatient dayAny reason for not meeting indicator needs to be documented in the chart (refusal, etc)
17after hospital admission. 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: Q Q4 2011; Site: Trinity Hospitals (52674)Data For: STK-1Data For: STK-1Benchmark Group Time Period Numerator Denominator % of PatientsAll ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %
18Discharged on Antithrombotic Therapy Imperative for stroke preventionThere needs to be documentation in the chart that patient was given prescription for antithrombotic medication at dischargeAcceptable medications include ASA, Aggrenox, Plavix, Ticlid, Lovenox, CoumadinLow dose anticoagulant to prevent DVT’s are insufficient as antithrombotic therapy to prevent recurrent strokes
19Discharged on Antithrombotic Therapy Antiplatelet or Anticoagulant are acceptableIf not prescribed, needs to be documented by the physician.Acceptable documentation:AllergicRefusalRisk for or actual bleedingSerious side effectsTerminal illness, comfort measures only
20Benchmark Group Time Period Numerator Denominator % of Patients STK-2Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.Time Period: Q Q4 2011Data For: STK-2Benchmark Group Time Period Numerator Denominator % of PatientsAll ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %
21Anticoagulation 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 documentationAllergyMental statusRefusalRisk of or actual bleedingRisk for fallsSerious side effects to medicationTerminal illness/comfort measures only
22Benchmark Group Time Period Numerator Denominator % of Patients STK-3Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge.Time Period: Q Q4 2011Data For: STK-3Benchmark Group Time Period Numerator Denominator % of PatientsAll ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %
23Thrombolytic TherapyIf 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 ageCare team cannot determine eligibilityLeft heart thrombusLife expectancy <1 yearNIHSS>22
24hours 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 3hours of time last known well.Time Period: Q Q4 2011Data For: STK-4Benchmark Group Time Period Numerator Denominator % of PatientsAll ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %
25Antithrombotic Therapy by end of Hospital Day 2 Must be administered by midnight of Day 2Antiplatelet (ASA, Aggrenox, Plavix, Ticlid) or Anticoagulant (Heparin IV, Lovenox, Coumadin, or arixtra)Acceptable documented reasons for not meeting:Risk of bleedingRefusalTerminal illnessAllergySerious side effect of medication
26Benchmark Group Time Period Numerator Denominator % of Patients STK-5Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2.Time Period: Q Q4 2011Data For: STK-5Benchmark Group Time Period Numerator Denominator % of PatientsAll ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %
27Discharged on Statin Medication The patient should be discharged on cholesterol reducing medication as part of preventionAcceptable documented reasons for not prescribing a statin on dischargeAllergyRefusalArrhythmiasHepatitisHypoglycemiaLiver failureRectal HemorrhageIntracranial HemorrhageRhabdomyolosis
28statin medication at hospital discharge. 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.Time Period: Q Q4 2011Data For: STK-6Benchmark Group Time Period Numerator Denominator % of PatientsAll ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %
29Stroke Education Required documentation for education Personal modifiable risk factors for strokeStroke Warning Signs and SymptomsHow to Activate EMS for StrokeNeed for Follow up after DischargeMedication informationStroke Coordinator consult at Trinity, that alerts the need for education to patients with strokes or TIA’s.
30Benchmark Group Time Period Numerator Denominator % of Patients 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.Time Period: Q Q4 2011Data For: STK-8Benchmark Group Time Period Numerator Denominator % of PatientsAll ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %
31Assessed for RehabAssessment must be completed by any one member of the Rehab team including:PhysiatristNeuro-psychologistPhysical TherapistOccupational TherapistSpeech Therapist
32Benchmark Group Time Period Numerator Denominator % of Patients STK-10Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services.Time Period: Q Q4 2011Data For: STK-10Benchmark Group Time Period Numerator Denominator % of PatientsAll ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %All ND Hospitals Q / %
33Data ReportsOnce 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.
35AnalysisReview 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’sNursing was not placing SCD’s on the patient or not documenting it in the HER.
36STK 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 pumpsDecember Included quality indicators in in-services on Ischemic stroke to make nursing staff more awareJanuary 2012-Worked with Clinical Nurse Educators on compliance with staffJanuary 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.
37Follow 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.
38GWTG Stroke Measures Door to MD evaluation-10 Minutes Door to CT Scan-25 minutesDoor to CT Scan Interpretation-45 minutesDoor to EKG-45 minutesDoor to Lab Results-45 minutesDoor to IV tPA-60 minutesDoor to CXR-45 minutesDoor to admission-3 hours
40Action PlanInstituted 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 patientOnce that was in place for several months began to break down the process and look at the data
41%Door To CT <= 25minPercent of patients who receive brain imaging within 25 minutes of arrivalTime Period: Q Q4 2011Data For: %Door To CT <= 25minBenchmark Group Time Period Numerator Denominator % of PatientsMy Hospital Q %My Hospital Q %My Hospital Q %My Hospital Q %All Hospitals Q %All Hospitals Q %All Hospitals Q %All Hospitals Q %
42Quality 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 delayRadiology (Delay in transport, logistics of transport, delay in staff coming to the ETC)?What % of our patients are getting CT in 25 minutes?
43Action Plan New PI Process form for timing of stroke alerts Educate staff on new formReview process of assessment with Nursing staff in the ETCContinue to work with Radiology regarding timeliness of CT scan results.Continue to follow up with involved departments
44Meaningful Use mandated in law to receive incentives Meaningful Use is using certified EHR technology toImprove quality, safety, efficiency, and reduce health disparitiesEngage patients and families in their health careImprove care coordinationImprove public healthAll the while maintaining privacy and securityMeaningful Use mandated in law to receive incentives
45What 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 careUse 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 ProgramCore measure data elements are captured manually from patients final billE-measures are captured electronicallyCore measure definitions come from a list that the abstractor chooses from (ICD-9 codes)Meaningful use measures come from SNOMED
47How to complyWill 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?
49MU: 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 patientsEmergency Department Throughput –admitted patients –Admission decision time to ED departure time for admitted patientsIschemic stroke –Discharge on anti-thromboticsIschemic stroke –Anticoagulation for A-fib/flutterIschemic stroke –Thrombolytic therapy for patients arriving within 2 hours of symptom onsetIschemic or hemorrhagic stroke –Antithrombotic therapy by day 2Ischemic stroke –Discharge on statinsIschemic or hemorrhagic stroke –Stroke educationIschemic or hemorrhagic stroke –Rehabilitation assessment10. VTE prophylaxis within 24 hours of arrivalIntensive Care Unit VTE prophylaxisAnticoagulation overlap therapyPlatelet monitoring on unfractionated heparinVTE discharge instructionsIncidence of potentially preventable VTE
50CMS Stroke Indicators Discharged on Antithrombotic Anticoagulation Therapy for At Fib/FlutterThrombolytic Therapy within 3 hours if patient arrives within 2 hoursAntithrombotic Therapy by end of Hospital Day 2Discharged on Statin MedicationStroke Education (Ischemic and Hemorrhagic)Assessed for Rehab (Ischemic and Hemorrhagic)
52The 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 specifiedEach 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):