Presentation on theme: "Becoming a Comprehensive Stroke Center"— Presentation transcript:
1 Becoming a Comprehensive Stroke Center SNCStroke & Neurovascular CenterNew JerseyNJBecoming a Comprehensive Stroke CenterJawad F. Kirmani, MDDirector Stroke & Neurovascular CenterProfessor, Seton Hall UniversitySpozhmy Panezai, MD; Mohammad Moussavi, MD; Martin Gizzi, MD, PhD; Thomas Steineke, MD; Stephen Bloomfield, MD; Gregory Przbylyski, MD; Asif Bashir, MD; Siddharat Mehta, MD; Noam Eshkar, MD; Daniel Korya, MD; Florence Chukwuneke, RN; Veronica Larson,RN NP; Charles Porbeni, MD; Nnamdi Uhegwu, MD; Madhu Gupta, MD
2 Stroke & Neurovascular Center SNCStroke & Neurovascular CenterNew JerseyNJ2012: 1st CSC NorthEast - JC2011: 2ndBiplanar Angiography SuiteArchitect of NJ’s Stroke Designation Law1996: NJ’s1st BiplanarAngiography Suite2013: Stroke Dedicated Critical Care Transport2011: InitiatedNCCU1995:NJ 1st Stroke Unit2007: NJ-DesignatedComprehensive Stroke Center1996:NJ’s 1stIV tPA use in stroke2014: Stroke Bays in ED with a built in CTIn 1991 the administration and Board of Directors of JFK Medical Center performed a needs survey for its primary and secondary service areas.At the time there was a lack of local neurological services available. Patients travelled to NYC or Philadelphia for this.It was determined that a tertiary neuroscience center was needed for the community and this would complement existing rehabilitation resources.There was also a large volume of cerebrovascular disease was identified in the community, many of whom were already coming to JFK for rehabilitation services.A void in advanced stroke care was also identified on surveying area hospitals.JFK Medical Center now has the rare combination of an acute care hospital, a tertiary-care Rehabilitation Institute and a tertiary-care Neuroscience Institute in one facility.These resources work together to provide state-of-the-art care to patients with cerebrovascular disease. Specialized clinical care, education and research are our daily life.In 1994, two years after the creation of the NJ Neuroscience Institute at JFK Medical Center, a stroke neurologist was hired and he created the state’s first stroke unit. Having participated in the original NIH-sponsored clinical trial of tPA in stroke, the Stroke Director was comfortable initiating the use of tPA and the Medical Center became part of the 6-hour tPA trial ATLANTIS. Since then, JFK Medical Center has remained on the cutting edge of tertiary stroke care with endovascular, surgical and medical innovations. One of our Stroke Directors has also served as the co-chair of Operation Stroke for Middlesex County, which was initiated as a demonstration project in Our current Chair of Neuroscience is the chair of the state’s Stroke Advisory Panel which reports to the NJ Department of Health and Senior Services. He also is a member of the Technical Advisory Panel for Comprehensive Stroke Center Certification at the Joint Commission.1983:NJ’s 1stBrain Trauma Unit1956: 1st Case of angiographic Fibrinolytic administration in US for stroke treatment
3 Steps to Advanced Certification Certification Eligibility CriteriaProgram in US or under charter of US congressIs within the JC accredited organizationMeets designated volume criteriaProgram Delivers Standardized clinical care – CPG’sPM and PI to improve its performance over timeApplication ProcessMeet the requirementsPerformance Measures
4 JFK Medical Center Stroke Program AHA/GWTG Gold Plus AwardAHA/GWTG Stroke Target Honor Roll AwardHealth GradesTop stroke hospital in NJ since 2003Top 100 in US since 2011
5 Stroke Program GoalsProvision of comprehensive clinical services within a seamless continuum of careProvision of patient, family and community educationRecruitment and retention of highly skilled medical and allied health professionalsRecognition as a national center of excellence for stroke care through research and education efforts related to cerebrovascular diseaseRapid assessment and treatment of all patients with acute and complex stroke to ensure optimal outcomes
6 Acute Stroke Team PATIENT 8hrs of Cerebrovascular CME + NIHSS Neurology Residents and FellowsBoard-Certified Vascular NeurologistsBoard-Certified ED PhysiciansNursing (ED or Stroke Unit)8hrs of Cerebrovascular CME + NIHSS8hrs of Cerebrovascular CEU + NIHSSNIHSScertified;adjunct toattendings
7 Core Stroke Committee Oversees Stroke Program PI Activities Develops, Reviews, & Revises Clinical Practice Guidelines(CPGs)Stroke NeurologistsStroke RegistrarVascular NeurosurgeonsStroke Nurse CoordinatorStroke APNNCC Unit & Stroke Unit Nurse ManagersEDNeuro-interventionalNeurocritical CareOversees StrokeProgram PIActivitiesAssesses Educational Outreach NeedsCSC dev’s CPGs based on the needs of our population; There is annual review (and more freq if needed) of CPG’s, on going revision; look at modifications document, look at population needsCoordinates carewith affiliatedPrimary StrokeCenters
8 Multidisciplinary Stroke Committee Approves CPGsDesigns tools for implementation and measurementPATIENTEMSEDCore Stroke CommitteePrivate Neurology StaffNursingRadiologyLaboratoryCase ManagementSocial WorkRehabilitationPharmacyQI CoordinatorInvolvement in PI ProcessAssesses compliance with Stroke Performance MeasuresAssesses compliance with CPGs
9 “Code Stroke!!!”PATIENTwith neurological change <24hrs durationEMSinitiates pre-hospital protocol and notifies ED of stroke patient arrivalCalled in ED or on Inpatient UnitsNextPager system to acute stroke team, CT, laboratory and EKGEMS Prehospital protocol: includes 12 lead EKG, glucose, HTN management at discretion of ED MD, ETA
10 PATIENT with neurological change <24hrs duration Acute Stroke Team responds immediately& performs NIHSSEKG Technologist responds immediately with study given to attending team memberCT Scan staff clears a scanner in preparationPhlebotomy responds immediately and labs are sent with stroke label as STAT
11 with neurological change <24hrs duration PATIENTwith neurological change <24hrs durationAcute Stroke Team determines eligibility for IV tPA, endovascular treatment or clinical trialTreatment decision based on history, NIHSS, CT results, laboratory data and BPAcute Stroke Team will administer acute therapy as appropriateNeurology consultation is called
12 Transfer Protocol JC/NJ State Designated CSC Have transfer agreements with 13 PSCs1-877-NJ-BLEEDAnswered by a Strokologist 24/7EmergencyNon-EmergencyCentral One call CCT informedBed board will call transferring facility when bed availableNCC arranges for bedResident/Fellow calls appropriate staffTransport: CCT or transferring facility arrangesBecause we are a state designated CSC, we have transfer agreements with PSCs .Other ways patients may enter our program:Emergency Stroke Transfers are those patients who will require emergent neurointerventional, neurosurgical, advanced neuroimaging, neurocritical care services, and enrollment in clinical trial.Non-Emergent Transfers are those patients that do not require immediate neurointerventional or neurosurgical services.This cell phone is carried and will be answered by the neuroscience resident or stroke fellow 24/7. They will determine whether the patient is an emergent or non-emergent transfer in consultation with the on call attending to determine the appropriate plan of care.All patients who meet eligibility/inclusion criteria for our established clinical practice guidelines, treatment protocols, and/or clinical trials will be accepted.Stroke Team meets patient in ED and begins assessmentTeam transports patient to appropriate location and performs handoff of care
13 Educational Outreach to PSCs Tele StrokeTele NCCEducational Outreach to EMS
14 Advanced Imaging Capabilities On site 24/7Computed Tomography (CT)CT Angiography (CTA)CT Perfusion (CTP)Magnetic Resonance Imaging (MRI)MR Angiography (MRA)Conventional AngiographyCarotid UltrasoundTranscranial Doppler and Extracranial UltrasonographyTransthoracic and Transesophageal EchocardiographyCertified Radiology Technicians available 24/7: ; for angiography/interventions we have a rad tech & nurse available 24/7 with an on call schedules after hours & on weekends
15 Staff Availability Physicians Available 24/7 2 Endovascular Neurologists4 Interventional Radiologists (neurointervention)5 Neuroradiologists2 Neuro-Intensivists & Medical Intensivists4 Vascular Neurologists2 Vascular Neurosurgeons4 Surgeons with expertise in carotid endarterectomyImaging Staff Available 24/7Certified Radiology Technicians, MRI Technologists, Endovascular Nurses & Technicians
16 Staff Availability Director of Inpatient Rehabilitation Rehabilitation StaffDirector of Inpatient RehabilitationDirector of JFK Rehabilitation Consult ServiceBoard Certified PhysiatristsPhysiatry ResidentsPT/OT- available 6 days, on call the 7thST- available 7 days a weekThe rehab services are directed by physician with expertise & experience in neuro-rehbPT/OT available 6 days, on call the 7th to perform pt assessment during the acute stroke phaseST available 7 days a week to perform swallowing function assessments
17 Inpatient Stroke Care NCCU 5+ dedicated NCCU beds Neurointensivists and Medical IntensivistsRN staff: 8 hrs stroke CEUs annually + NIHSS certifiedStroke Unit8 bed unit with telemetry monitoringRN staff – Inpatient Code Stroke responders8 hrs of stroke education annually + NIHSS certifiedAccess CenterMultidisciplinary services available to patients everywhere
18 Cerebrovascular Program Fellowships Jawad F. Kirmani, MDVASCULAR NEUROLOGY FELLOWSHIPYEAR 1ABCNEUROCRITICALCARE FELLOWSHIPSTROKE RESEARCH/CLINICAL TRIALS FELLOWSHIPENDOVASCULAR SURGICAL NEURORADIOLOGY FELLOWSHIPOngoing Clinical an Basic Science ResearchAYEARS 2 , 3 and 4AACAROTID DOPPLERS/ TCD’S TRAININGANGIOGRAPHY VASCULAR FELLOWS
19 Care Coordination Multidisciplinary Approach: PT/OT/ST, Social Work, Case Management, Pharmacy, Rehabilitation, Nursing, Physician(s)Expertise regarding neurology & stroke careKnowledge of different levels of rehab & appropriate referralCommunity resourcesMultidisciplinary RoundsStroke Education; Our Sws & CMs have expertise re: neurology and stroke care, different levels of rehab & knowledge of referrals to appropriate level of rehab.SW can make appropriate referrals for SAR, Outpt care, home services, palliative care. DME, respite care, risk factor education
20 Care Coordination Post Hospital Planning: Social Work and Case Management coordinate with other team members to prepare patient and family for discharge and/or next level of careContinuum of Services including Acute Rehab (on site), Long Term Care, Outpatient Rehab, Home Care Services, Palliative Care, and referrals to Respite Care Services and Adult Day CareIn addition to acute rehab
21 Community EducationLarge volume of ischemic stroke & hemorrhagic strokeCommunity education focus :Recognizing stroke as an emergencySymptoms recognitionActivation of EMSPrimary & Secondary Prevention
22 Meeting Community Needs Needs assessment 2011, increased stroke market share 7.5% in past 3 yearsFocus groups interviewed to assess opinion, needs, and feelingsFocused strategic planning with Medical/Dental StaffClinical Vision Steering CommitteeRecommended priority tactics and actionsNeeds assessment for entire facility ; reported 2011 ; Found that we had increased our stroke market share by 7.5% in past 3 yrs.There was a focused strategic group which involved med staff; they created a clinical vision steering committeeExpand number of procedures we could do; to expand& provide more comprehensive stroke care & have qualified staff
23 Needs Assessment: Focus Groups Residents of primaryand secondary areasAge 45-65Ethnic/minority healthIssues: Asian, Hispanic,Asian Indian, andAfrican-American4 focus groups were 1 focus group for each our service areas. And additional focus groups for the various ethnicities.
24 Needs Assessment: Identified Strategies Specialized ED treatment space to accommodate stroke patientsUpgrade interventional radiology suite to support service growth with emphasis on neuroradiology and specialty proceduresEnhance EMS relationships to promote program awarenessImprove process to expedite transfers and admissionsBroaden stroke network and enhance referralsPromote quality outcomes and performance data to community
26 Selection and Implementation of CPGs Focus on Thrombolysis and Reduction ofPeristroke ComplicationsEmergency Management of Acute Ischemic StrokeFocus on AntithromboticsIdentification of SourcesSecondary Stroke PreventionInpatient Treatment of StrokeFocus on Management of ICH and Reduction of Peristroke ComplicationsManagement of Hemorrhagic StrokeFocus on Monitoring, Rapid Work Up, and Stroke PreventionTransient Ischemic Attack with Observational Servicesinterdisciplinary interventions addressing reduction of peristroke complicationsManagement of Aneurysmal Subarachnoid HemorrhageFocus on Management of Peristroke ComplicationsEndovascular Procedures GuidelinesFocus on Appropriate Use of Procedures
28 Implementation and Evaluation Performance improvementQI CoordinatorStroke NurseCoordinatorCore StrokeCommitteeAlong with QI, The Stroke Nurse Coordinator also tracks all of these measures for compliance. tracking compliance with required stroke measuresConcurrent tracking of compliance with orders, smoking cessation, patient stroke education, stroke measuresConcurrent tracking of code stroke processConcurrent tracking of stroke order sheet use
29 Stroke Measures JC 8 Core Stroke Measures Dysphagia Screening Smoking CessationCode Stroke Response TimesCode Stroke calledDoor to MD contactDoor to CT doneCT done to readLabs & EKG ordered to readDoor to DrugIn Hospital complicationsUTI, DVT, and pneumoniaTime to assemble team: add in as PI measure if we get from J
30 Implementation and Evaluation Performance Improvement ProcessWeekly clinical quality meeting reviews ED cases, admissions and dischargesMonthly retrospective data analysis by the Multidisciplinary Stroke CommitteeRetrospective data presentation to JFKMC PI committee (Med Exec & Board)
31 Medical Peer Review Process: Comprehensive Stroke Care Generic ScreensIdentified IssuesDepartment/DivisionQuality ReviewMedical Staff ComprehensiveStroke Review Committee(Quarterly)TrendsDepartment ChairpersonRespective DepartmentPerformance ImprovementCommittee(Semi Annually)TrendsTrendsTrendsMedicalExecutive CommitteeBoard of Directors
32 SNC Radiology Code Stroke ED/EMS/CCT Stroke Floor/Unit NEUROLOGY AttendingVascular FellowAttendingNEUROLOGYNeurology ResidentED/EMS/CCTStroke Floor/UnitAttendingVascular FellowResidentNursesPT/OT/ST/RehabNeuro CCUAttendingNCC FellowResidentNurses/NPSNCNeuro-InterventionAttendingEndovascular FellowNeuro/vascularsurgeryVascular FellowWe heal.The Clinical structure of the services provided by the Comprehensive Stroke Center are tailored to provide the most comprehensive care to each stroke patient who presents to UH, but also to provide education and outreach to help prevent first and recurrent strokes.Stroke ClinicsAttendingCardiologyEndovascular FellowVascular FellowNursesAnesthesiologyStroke EducationOutreachAttendingVascular FellowEndovascular FellowNurses
33 Advanced Disease- Specific Care Certification Core Standards: Recommendations for Comprehensive Stroke Centers: A Consensus Statement from the Brain Attack Coalition. Brain Attack Coalition and American Stroke Association, Stroke 2005.Advanced Disease- Specific Care Certification Core Standards:Program Management (PR)Delivering/Facilitating Clinical Care (DF)Supporting Self-Management (SE)Clinical Information Management (CT)Performance Measurement (PM)The JC’s program req’s were derived from the BAC& ASA’s publication: as above; The DSC core standards serve as the platform for CSC requirements. In 2011 a multidisciplinary advisory panel convened to provide the JC with additional recommendations during the development of the CSC Cert program req’s.
34 EligibilityVolume20 or more patients per year with a diagnosis of aneurysmal subarachnoid hemorrhage.15 or more endovascular coiling or surgical clipping procedures for aneurysm are performed per year.Administration of IV tPA to 25 eligible patients per yearOver 2 year average countsIVtpA given over Tele stroke at another hospital countsIVtpA given at another hospital that is then transferred countsIV tPA ordered and monitored by the CSC via telemedicine with administration occurring at another hospital.IV tPA administered by another hospital which then transferred the patient to the comprehensive stroke center.
35 Eligibility Advanced Imaging Capabilities Available on-site 24 hours a day, 7 days a weekCatheter angiographyCT angiographyMR angiography-MRAMRI, including diffusion weighted MRITranscranial DopplerCarotid duplex ultrasound Extracranial ultrasonographyTransesophageal EchocardiographyTransthoracic EchocardiographyIV tPA ordered and monitored by the CSC via telemedicine with administration occurring at another hospital.IV tPA administered by another hospital which then transferred the patient to the comprehensive stroke center.
36 Eligibility Post Hospital Care Coordination for Patients Dedicated Neuro-Intensive Care Unit for Complex Stroke PatientsPeer Review ProcessParticipation in Clinical Stroke Research (IRB approved)Performance MeasuresThe hospital will have dedicated neuro-intensive care unit (ICU) beds for complex stroke patients, that include staff and licensed independent practitioners with the expertise and experience to provide neuro-critical care 24 hours a day, 7 days a week.Peer Review:The hospital will have a peer review process to review and monitor the care provided to patients with ischemic stroke, subarachnoid hemorrhage and administration of tPA.The CSC will participate in IRB-approved, patient-centered stroke research.Perf Measures: Initially CSCs must continue to meet the performance measures requirements for primary stroke centers.
37 JC Core Measure for Primary Stroke Centers DVT Prophylaxis by hospital day 2Antithrombotics by hospital day 2Discharged on AntithromboticsAnticoagulation for Patients with Atrial FibrillationtPA givenDischarged on StatinStroke EducationPlan for Rehabilitation
38 CSTK Draft Measures CSTK-01 NIHSS on Arrival CSTK Modified Rankin Score (mRS) at 90 daysCSTK Severity Measurement on Arrival SAH/ICHCSTK INR Reversal AchievedCSTK-04a Median Time to Treatment with a Procoagulant Reversal AgentCSTK-04b Median Time to INR ReversalCSTK Hemorrhagic Complication (Overall)CSTK-05a Hemorrhagic Complication for Patients treated with IV tPAwithout catheter based reperfusionCSTK-05b Hemorrhagic Complication for Patients treated with IAThrombolytic Therapy or Mechanical Endovascular Procedurewith or without IV tPACSTK Nimodipine Treatment InitiatedCSTK Median Time to Recanalization TherapyCSTK-7a Thrombolysis in Cerebral Infarction (TICI)Post Treatment Reperfusion GradeBeing piloted now
39 Stroke & Neurovascular Center SNCStroke & Neurovascular CenterNew JerseyNJ2012: 1st CSC NorthEast - JC2011: 2ndBiplanar Angiography SuiteArchitect of NJ’s Stroke Designation Law1996: NJ’s1st BiplanarAngiography Suite2013: Stroke Dedicated Critical Care Transport2011: InitiatedNCCU1995:NJ 1st Stroke Unit2007: NJ-DesignatedComprehensive Stroke Center1996:NJ’s 1stIV tPA use in stroke2014: Stroke Bays in ED with a built in CTIn 1991 the administration and Board of Directors of JFK Medical Center performed a needs survey for its primary and secondary service areas.At the time there was a lack of local neurological services available. Patients travelled to NYC or Philadelphia for this.It was determined that a tertiary neuroscience center was needed for the community and this would complement existing rehabilitation resources.There was also a large volume of cerebrovascular disease was identified in the community, many of whom were already coming to JFK for rehabilitation services.A void in advanced stroke care was also identified on surveying area hospitals.JFK Medical Center now has the rare combination of an acute care hospital, a tertiary-care Rehabilitation Institute and a tertiary-care Neuroscience Institute in one facility.These resources work together to provide state-of-the-art care to patients with cerebrovascular disease. Specialized clinical care, education and research are our daily life.In 1994, two years after the creation of the NJ Neuroscience Institute at JFK Medical Center, a stroke neurologist was hired and he created the state’s first stroke unit. Having participated in the original NIH-sponsored clinical trial of tPA in stroke, the Stroke Director was comfortable initiating the use of tPA and the Medical Center became part of the 6-hour tPA trial ATLANTIS. Since then, JFK Medical Center has remained on the cutting edge of tertiary stroke care with endovascular, surgical and medical innovations. One of our Stroke Directors has also served as the co-chair of Operation Stroke for Middlesex County, which was initiated as a demonstration project in Our current Chair of Neuroscience is the chair of the state’s Stroke Advisory Panel which reports to the NJ Department of Health and Senior Services. He also is a member of the Technical Advisory Panel for Comprehensive Stroke Center Certification at the Joint Commission.1983:NJ’s 1stBrain Trauma Unit1956: 1st Case of angiographic Fibrinolytic administration in US for stroke treatment
42 Standard PR: Program Management PR1: The program defines its leadership roles.
43 Medical Executive Committee Primary Medical Doctors & JFKMCSTROKE CENTER ORGANIZATIONExecutive VP & System COOExecutive VP & COO JFKMedical Executive CommitteeChairman of NSIDirector Stroke & Neurovascular CenterChief Medical OfficerVascular NeurologistsNeurointerventionalistsNeurointensivistsNeurosurgeryNeuroradiologyNCCU/ Neurointervention DirectorStroke Center DirectorPrimary Medical Doctors &Private NeurologistsEmergency Department DirectorRehabilitation Director1.The Executive VP and COO of JFK Health System: responsible for the overall vision of clinical services across all JFK Health System campuses. This includes decisions about the coordination and delivery of cerebrovascular services. The Executive VP and COO of JFK oversee all of the hospital staff divisions, including the NJ Neuroscience Institute, nursing, pharmacy, radiology, laboratory and inpatient therapies.2.Chairman of the NJ Neuroscience Institute. Medical and administrative oversight of the program The Chairman also ensures compliance with the cerebrovascular plan of care among the members of the Stroke Team.3.Stroke Center Director: Daily medical direction,operation of the cerebrovascular program ,creation and implementation of policies for cerebrovascular diseases,-principal liaison to hospital nursing staff, the private neurology attendings, the primary medical doctors, the emergency physicians, emergency medical services personnel, the Director of the Neurocritical Care Unit/ Cerebrovascular Services, the neuroradiologists, neurointensivists, vascular neurologists, and neurosurgery .-supervises the performance of the neurology residents and attendings and directs the Clinical Stroke Coordinator.4. Clinical Stroke Coordinator, an RN, implements care plans through education of nursing staff throughout the Medical Center,tracks compliance with care plans on a daily basis and directs the Stroke Registrar who collects concurrent data on all stroke and TIA admissions.5. The Stroke Advanced Practice Nurse (APN): provides a higher level of nursing supervision for acute stroke and complex stroke patients in the stroke units and NCCU. The Stroke APN is a Clinical Nurse Specialist who is an expert in critical care, neurocritical care, and stroke.Other designated nursing care managers and directors provide overall coordination and leadership throughout the hospital.Specialized nursing care services are overseen by the nursing director of 3 Central, the neuroscience floor, which includes the stroke unit and the nurse manager of the ICU which contains the designated Neurocritical Care Unit.Neuroscience Residents, Fellows, AttendingsEmergency Medical ServicesClinical and Allied Health Services(PT/OT/Speech)(Dietary/Lab)DirectorPatient Care ServicesQI CoordinatorStroke CoordinatorStroke APNDirectorOf Social Work and Case ManagementStroke RegistrarClinical Trials CoordinatorsNursing
44 Private Neurology Staff Standard PR.2: The program is designed, implemented, andevaluated collaboratively.Multidisciplinary Stroke CommitteePATIENTEMSEDCore Stroke CommitteePrivate Neurology StaffNursingRadiologyLaboratoryCase managementSocial workRehabilitationPharmacyQI Coordinatordesigns tools for implementation and measurementapproves CPGsThis group meets monthly to design the processes of stroke care and the performance improvement plans. Data are assessed in these same meetings on a monthly basis. Decisions made in this committee are communicated to individual departments by the directors sitting on the committee. Changes in policy emanating from this committee are presented to the hospital’s PI committee and approval is sought from the medical executive committee when necessary.assesses compliance with quality measuresassesses compliance with CPGs
45 Neuro-Intervention/NCCU Standard PR.2: The program is designed, implemented, and evaluated collaboratively.JFK Medical Center Squad CouncilPATIENTEMSEDCore Stroke CommitteeNeuro-Intervention/NCCUEMS/EMT/Squad representatives, ED administrative staff and Neuroscience stroke program neurologist, stroke coordinator and interventional radiologists meets quarterly to discuss concerns and projects to improve EMS/EMT interactions with the ED thereby improving patient outcomes. Stroke continuing education on topics such as acute stroke interventions (IV TPA therapy, Mechanical Thrombolysis), acute stroke clinical trials, and protocols are provided to members and discussions on any update to our stroke program are also shared during these meetings. EMS is also part of the multidisciplinary stroke committee.
46 Standards: The Program…. PR3- meets the needs of the target population and/or health care service areaNeeds survey, program missionPR4- follows a code of ethicsPR5- complies with applicable laws and regulationsPR6- has current reference and resource materials readily availableClinical Practice Guidelines-hospital intranetStandard written order sets- patient care areasPR7- facilities are safe and readily accessible PR3- In 1991 the administration and board of directors of JFK Medical Center performed a needs survey for its primary and secondary service areas. It was determined that a tertiary neuroscience center was needed for the community and would complement existing rehabilitation resources. A large volume of cerebrovascular disease was identified in the community, many of whom were already coming to JFK for rehabilitation services. A void in advanced stroke care was also identified on surveying area hospitals.The mission of the Comprehensive Stroke Program at JFK Medical Center is to provide an outstanding level of comprehensive and specialized care to patients who have cerebrovascular disease in our community and regionally. This care is provided through a coordinated, multidisciplinary approach.PR6- Copies of the order sets are maintained in each applicable patient care area. Additionally the clinical practice guidelines are available on the hospital intranet. Staff educational materials are also available on the hospital intranet.
47 Clinical Practice Guidelines Emergency Management of Acute Ischemic StrokeInpatient Treatment of StrokeManagement of Hemorrhagic StrokeTransient Ischemic Attack with Observational ServicesManagement of Aneurysmal Subarachnoid HemorrhageEndovascular Procedures Guidelines
48 PR8- The Program communicates to participants the scope and level of care, treatment, and services it provides.Advanced Imaging CapabilitiesProcedures:Aneurysms: Microsurgical Neurovascular Clipping/ Neuroendovascular CoilingExtracranial Carotid Artery Stenting/ EndarterectomyStaff Availability (24/7)Physicians2 Endovascular NeurologistsInterventional Radiologists ● NeuroradiologistsVascular Neurologists ● Vascular NeurosurgeonsNeuro-Intensivists & Medical IntensivistsSurgeons with expertise in carotid endarterectomyImaging Staff Available 24/7Certified Radiology Technicians, MRI Technologists, Endovascular Nurses & TechniciansOn call schedule available;
49 Staff Availability Rehabilitation Staff Advanced Practice Nurse Director: Expertise & experience in neuro-rehabilitationDirector of Inpatient RehabilitationDirector of JFK Rehabilitation Consult ServicePT/OT- available 6 days, on call the 7thST- available 7 days a weekAdvanced Practice NurseSupport delivery of evidence based acute stroke assessment and managementExpert nursing consultation and oversightDevelop and deliver acute stroke continuing education programsParticipate in PI processes and CSC researchThe rehab services are directed by physician with expertise & experience in neuro-rehbPT/OT available 6 days, on call the 7th to perform pt assessment during the acute stroke phaseST available 7 days a week to perform swallowing function assessments
50 PR10- Eligible patients have access to the program PR9- The scope and level of care, treatment, and services provided are comparable for individuals with the same acuity and type of disease being managedCode Stroke Process24/7 availability of neurological assessment for IV tPAPR10- Eligible patients have access to the programThe Neuroscience Residents/Fellows are available on-site 24/7 to perform assessment of candidates for tPA. Neuroscience Attendings are available either on-site or via consultation 24/7.
51 Standard DF: Delivering/Facilitating Clinical Care DF1: Practitioners are qualified and competentDF2: The program develops a standardized process originating in clinical practice guidelines (CPG) or evidence-based practice to deliver or facilitate the delivery of clinical care.Patient assessed to identify post hospital care requirementsDF3: The program is designed to meet the participant’s needs.DF.4: The program manages co-morbidities and concurrently occurring conditions and/or communicates the necessary information to manage these conditions to appropriate practitioners.Transfer ProtocolsAll members of the core stroke team and staff caring for patients must have at least 8hrs of stroke education & NIHSS certification.Committee has defined the patient assessment process. This is described in the Emergency Management of Acute Ischemic Stroke CPG. The code stroke process, including the stroke evaluation performed by neurology residents, fellows, and faculty, is described in the CPG and documented on the stroke assessment form.Our stroke program, through its Core Stroke Committee and its Multidisciplinary StrokeDF2 Patient assessed to identify post hospital care requirements (AR, SAR, SNIF etc) & family members/caregivers assessed to determine readiness to provide pt care
52 Standard SE: Supporting Self Management SE1: The program involves participants in making decisions about managing their disease or condition.SE2:The program addresses lifestyle changes that support self-management regimens.Stroke Patient/Family Education bookletStroke Care Discharge Instruction SheetSE.3: The program addresses participants’ education needs.Post hospital care, durable medical equipment, respite careCSC sponsors at least 2 public educational activities that focus on stroke prevention annuallyInformed written consent is obtained from patients or their family member(s) for any stroke interventions including intra-arterial tPA, mechanical thrombectomy, diagnostic angiography, angioplasty, stenting, embolization, and coiling. Written informed consent is also obtained for any surgical/neurosurgical stroke treatments. Written informed consent is not obtained for IVtPA, however a thorough discussion about IV tPA,including risks, benefits, alternative treatments, is undertaken with the patient and family members by the stroke team.SE2: education instruction & booklet Stroke Patient/Family Education booklet which includes information about the event (causes, signs and symptoms, treatment and patient/family stroke risk factors) as well as desirable lifestyle modifications. Information on living at home after a stroke as well as potential rehabilitation care strategies in the home setting is likewise included. In addition to this standard booklet, any patient with other co-morbid conditions such as Diabetes Mellitus, Atrial Fibrillation, Aphasia, Hypertension, etc. are also given specific resource materials regarding these conditions from the American Stroke Association.Stroke Care Instruction Sheet given on discharge. This sheet lists the individual’s lifestyle changes that they are required to follow upon discharge. This sheet is tailored to each individual and includes their discharge blood pressure, cholesterol levels, A1C level, current weight and discharge diet. It also reviews information on exercise, diet/weight, smoking cessation, and diabetes.
54 Standard PM: Performance Measurement PM1: The program has an organized, comprehensive approach to performance improvement.Peer Review ProcessCollection of data:Periprocedure complication rates for:Placement of transducer & ventriculostomyPerformance of decompressive craniectomy & endovascular recanalizationVolume requirementsFollow up phone callsCSC publicly reports outcomes related to interventional proceduresPm1: CSC ,ust have peer review process to review all pts tx’d .The Multidisciplinary Stroke Committee completes a quarterly and yearly PI Report and Appraisal which includes specific stroke performance measures and indicators. Data is collected concurrently on active patients as well as monthly by chart review and includes the required Joint Commission performance measures, response time indicators, functional outcomes and patient satisfaction measures.
55 Performance improvement QI CoordinatorStroke NurseCoordinatorCore StrokeCommitteeAlong with QI, The Stroke Nurse Coordinator also tracks all of these measures for compliance. tracking compliance with required stroke measuresConcurrent tracking of compliance with orders, smoking cessation, patient stroke education, stroke measuresConcurrent tracking of code stroke processConcurrent tracking of stroke order sheet use
56 Stroke Measures JC 8 Core Stroke Measures Dysphagia Screening Smoking CessationCode Stroke Response TimesCode Stroke calledDoor to MD contactDoor to CT doneCT done to readLabs & EKG ordered to readDoor to DrugIn Hospital complicationsUTI, DVT, and pneumoniaStroke MeasuresTime to assemble team: add in as PI measure if we get from J
57 Standard PM: Performance Measurement PM2: The program uses measurement data to evaluate processes and outcomes.Stroke registryAnalysis of measurement dataComplication rates for CEA & CAS (<6%)Diagnostic catheter angiographyPeriprocedure stroke and death rate ≤ 1%Aggregate serious complication rate ≤ 2%PM3: The program maintains data quality and integrity.PM3:The data elements are defined in detail and the process for abstracting data are included in the Stroke PI data dictionary. The program monitors data reliability (including accuracy and completeness) and validity on an ongoing basis and verifies that data bias is minimized.
58 Standard PM: Performance Measurement PM4: The process for identifying, reporting, managing, and tracking sentinel events is defined and implemented.PM5: The program collects and analyzes data regarding variance from the clinical practice guidelines to improve the standardized process.PM6: The program evaluates participant perception of the quality of care.PM5: The acute stroke protocols and order sets are reviewed regularly by the Core Stroke Committee and updated based on data analysis results and current literature.PM6:The stroke patient’s perception of care is captured by reviewing Press Ganey reports. In addition, each Stroke / TIA patient is given a Stroke Care Survey to complete and return to the unit. The data is collected, evaluated and reviewed at the Multidisciplinary Stroke Committee meetings and posted on the Stroke Performance Improvement bulletin board. Changes in practice and care are considered after surveys are reviewed.