Becoming a Comprehensive Stroke Center

Becoming a Comprehensive Stroke Center
SNC Stroke & Neurovascular Center New Jersey NJ Becoming a Comprehensive Stroke Center Jawad F. Kirmani, MD Director Stroke & Neurovascular Center Professor, Seton Hall University Spozhmy 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

Stroke & Neurovascular Center
SNC Stroke & Neurovascular Center New Jersey NJ 2012: 1st CSC NorthEast - JC 2011: 2nd Biplanar Angiography Suite Architect of NJ’s Stroke Designation Law 1996: NJ’s 1st Biplanar Angiography Suite 2013: Stroke Dedicated Critical Care Transport 2011: Initiated NCCU 1995: NJ 1st Stroke Unit 2007: NJ-Designated Comprehensive Stroke Center 1996: NJ’s 1st IV tPA use in stroke 2014: Stroke Bays in ED with a built in CT In 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 Unit 1956: 1st Case of angiographic Fibrinolytic administration in US for stroke treatment

Steps to Advanced Certification
Certification Eligibility Criteria Program in US or under charter of US congress Is within the JC accredited organization Meets designated volume criteria Program Delivers Standardized clinical care – CPG’s PM and PI to improve its performance over time Application Process Meet the requirements Performance Measures

JFK Medical Center Stroke Program
AHA/GWTG Gold Plus Award AHA/GWTG Stroke Target Honor Roll Award Health Grades Top stroke hospital in NJ since 2003 Top 100 in US since 2011

Stroke Program Goals Provision of comprehensive clinical services within a seamless continuum of care Provision of patient, family and community education Recruitment and retention of highly skilled medical and allied health professionals Recognition as a national center of excellence for stroke care through research and education efforts related to cerebrovascular disease Rapid assessment and treatment of all patients with acute and complex stroke to ensure optimal outcomes

Acute Stroke Team PATIENT 8hrs of Cerebrovascular CME + NIHSS
Neurology Residents and Fellows Board-Certified Vascular Neurologists Board-Certified ED Physicians Nursing (ED or Stroke Unit) 8hrs of Cerebrovascular CME + NIHSS 8hrs of Cerebrovascular CEU + NIHSS NIHSS certified; adjunct to attendings

Core Stroke Committee Oversees Stroke Program PI Activities
Develops, Reviews, & Revises Clinical Practice Guidelines (CPGs) Stroke Neurologists Stroke Registrar Vascular Neurosurgeons Stroke Nurse Coordinator Stroke APN NCC Unit & Stroke Unit Nurse Managers ED Neuro-interventional Neurocritical Care Oversees Stroke Program PI Activities Assesses Educational Outreach Needs CSC 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 needs Coordinates care with affiliated Primary Stroke Centers

Multidisciplinary Stroke Committee
Approves CPGs Designs tools for implementation and measurement PATIENT EMS ED Core Stroke Committee Private Neurology Staff Nursing Radiology Laboratory Case Management Social Work Rehabilitation Pharmacy QI Coordinator Involvement in PI Process Assesses compliance with Stroke Performance Measures Assesses compliance with CPGs

“Code Stroke!!!” PATIENT with neurological change <24hrs duration EMS initiates pre-hospital protocol and notifies ED of stroke patient arrival Called in ED or on Inpatient Units Next Pager system to acute stroke team, CT, laboratory and EKG EMS Prehospital protocol: includes 12 lead EKG, glucose, HTN management at discretion of ED MD, ETA

PATIENT with neurological change <24hrs duration
Acute Stroke Team responds immediately& performs NIHSS EKG Technologist responds immediately with study given to attending team member CT Scan staff clears a scanner in preparation Phlebotomy responds immediately and labs are sent with stroke label as STAT

with neurological change <24hrs duration
PATIENT with neurological change <24hrs duration Acute Stroke Team determines eligibility for IV tPA, endovascular treatment or clinical trial Treatment decision based on history, NIHSS, CT results, laboratory data and BP Acute Stroke Team will administer acute therapy as appropriate Neurology consultation is called

Transfer Protocol JC/NJ State Designated CSC
Have transfer agreements with 13 PSCs 1-877-NJ-BLEED Answered by a Strokologist 24/7 Emergency Non-Emergency Central One call CCT informed Bed board will call transferring facility when bed available NCC arranges for bed Resident/Fellow calls appropriate staff Transport: CCT or transferring facility arranges Because 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 assessment Team transports patient to appropriate location and performs handoff of care

Educational Outreach to PSCs
Tele Stroke Tele NCC Educational Outreach to EMS

Advanced Imaging Capabilities
On site 24/7 Computed Tomography (CT) CT Angiography (CTA) CT Perfusion (CTP) Magnetic Resonance Imaging (MRI) MR Angiography (MRA) Conventional Angiography Carotid Ultrasound Transcranial Doppler and Extracranial Ultrasonography Transthoracic and Transesophageal Echocardiography Certified 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

Staff Availability Physicians Available 24/7
2 Endovascular Neurologists 4 Interventional Radiologists (neurointervention) 5 Neuroradiologists 2 Neuro-Intensivists & Medical Intensivists 4 Vascular Neurologists 2 Vascular Neurosurgeons 4 Surgeons with expertise in carotid endarterectomy Imaging Staff Available 24/7 Certified Radiology Technicians, MRI Technologists, Endovascular Nurses & Technicians

Staff Availability Director of Inpatient Rehabilitation
Rehabilitation Staff Director of Inpatient Rehabilitation Director of JFK Rehabilitation Consult Service Board Certified Physiatrists Physiatry Residents PT/OT- available 6 days, on call the 7th ST- available 7 days a week The rehab services are directed by physician with expertise & experience in neuro-rehb PT/OT available 6 days, on call the 7th to perform pt assessment during the acute stroke phase ST available 7 days a week to perform swallowing function assessments

Inpatient Stroke Care NCCU 5+ dedicated NCCU beds
Neurointensivists and Medical Intensivists RN staff: 8 hrs stroke CEUs annually + NIHSS certified Stroke Unit 8 bed unit with telemetry monitoring RN staff – Inpatient Code Stroke responders 8 hrs of stroke education annually + NIHSS certified Access Center Multidisciplinary services available to patients everywhere

Cerebrovascular Program Fellowships
Jawad F. Kirmani, MD VASCULAR NEUROLOGY FELLOWSHIP YEAR 1 A B C NEUROCRITICAL CARE FELLOWSHIP STROKE RESEARCH/ CLINICAL TRIALS FELLOWSHIP ENDOVASCULAR SURGICAL NEURORADIOLOGY FELLOWSHIP Ongoing Clinical an Basic Science Research A YEARS 2 , 3 and 4 A A CAROTID DOPPLERS/ TCD’S TRAINING ANGIOGRAPHY VASCULAR FELLOWS

Care Coordination Multidisciplinary Approach:
PT/OT/ST, Social Work, Case Management, Pharmacy, Rehabilitation, Nursing, Physician(s) Expertise regarding neurology & stroke care Knowledge of different levels of rehab & appropriate referral Community resources Multidisciplinary Rounds Stroke 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

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 care Continuum 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 Care In addition to acute rehab

Community Education Large volume of ischemic stroke & hemorrhagic stroke Community education focus : Recognizing stroke as an emergency Symptoms recognition Activation of EMS Primary & Secondary Prevention

Meeting Community Needs
Needs assessment 2011, increased stroke market share 7.5% in past 3 years Focus groups interviewed to assess opinion, needs, and feelings Focused strategic planning with Medical/Dental Staff Clinical Vision Steering Committee Recommended priority tactics and actions Needs 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 committee Expand number of procedures we could do; to expand& provide more comprehensive stroke care & have qualified staff

Needs Assessment: Focus Groups
Residents of primary and secondary areas Age 45-65 Ethnic/minority health Issues: Asian, Hispanic, Asian Indian, and African-American 4 focus groups were 1 focus group for each our service areas. And additional focus groups for the various ethnicities.

Needs Assessment: Identified Strategies
Specialized ED treatment space to accommodate stroke patients Upgrade interventional radiology suite to support service growth with emphasis on neuroradiology and specialty procedures Enhance EMS relationships to promote program awareness Improve process to expedite transfers and admissions Broaden stroke network and enhance referrals Promote quality outcomes and performance data to community

Selection and Implementation of CPGs

Selection and Implementation of CPGs
Focus on Thrombolysis and Reduction of Peristroke Complications Emergency Management of Acute Ischemic Stroke Focus on Antithrombotics Identification of Sources Secondary Stroke Prevention Inpatient Treatment of Stroke Focus on Management of ICH and Reduction of Peristroke Complications Management of Hemorrhagic Stroke Focus on Monitoring, Rapid Work Up, and Stroke Prevention Transient Ischemic Attack with Observational Services interdisciplinary interventions addressing reduction of peristroke complications Management of Aneurysmal Subarachnoid Hemorrhage Focus on Management of Peristroke Complications Endovascular Procedures Guidelines Focus on Appropriate Use of Procedures

Performance Improvement Initiatives & Peer Review

Implementation and Evaluation
Performance improvement QI Coordinator Stroke Nurse Coordinator Core Stroke Committee Along with QI, The Stroke Nurse Coordinator also tracks all of these measures for compliance. tracking compliance with required stroke measures Concurrent tracking of compliance with orders, smoking cessation, patient stroke education, stroke measures Concurrent tracking of code stroke process Concurrent tracking of stroke order sheet use

Stroke Measures JC 8 Core Stroke Measures Dysphagia Screening
Smoking Cessation Code Stroke Response Times Code Stroke called Door to MD contact Door to CT done CT done to read Labs & EKG ordered to read Door to Drug In Hospital complications UTI, DVT, and pneumonia Time to assemble team: add in as PI measure if we get from J

Implementation and Evaluation
Performance Improvement Process Weekly clinical quality meeting reviews ED cases, admissions and discharges Monthly retrospective data analysis by the Multidisciplinary Stroke Committee Retrospective data presentation to JFKMC PI committee (Med Exec & Board)

Medical Peer Review Process: Comprehensive Stroke Care
Generic Screens Identified Issues Department/Division Quality Review Medical Staff Comprehensive Stroke Review Committee (Quarterly) Trends Department Chairperson Respective Department Performance Improvement Committee (Semi Annually) Trends Trends Trends Medical Executive Committee Board of Directors

SNC Radiology Code Stroke ED/EMS/CCT Stroke Floor/Unit NEUROLOGY
Attending Vascular Fellow Attending NEUROLOGY Neurology Resident ED/EMS/CCT Stroke Floor/Unit Attending Vascular Fellow Resident Nurses PT/OT/ST/Rehab Neuro CCU Attending NCC Fellow Resident Nurses/NP SNC Neuro-Intervention Attending Endovascular Fellow Neuro/vascular surgery Vascular Fellow We 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 Clinics Attending Cardiology Endovascular Fellow Vascular Fellow Nurses Anesthesiology Stroke Education Outreach Attending Vascular Fellow Endovascular Fellow Nurses

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.

Eligibility Volume 20 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 year Over 2 year average counts IVtpA given over Tele stroke at another hospital counts IVtpA given at another hospital that is then transferred counts IV 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.

Eligibility Advanced Imaging Capabilities
Available on-site 24 hours a day, 7 days a week Catheter angiography CT angiography MR angiography-MRA MRI, including diffusion weighted MRI Transcranial Doppler Carotid duplex ultrasound Extracranial ultrasonography Transesophageal Echocardiography Transthoracic Echocardiography IV 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.

Eligibility Post Hospital Care Coordination for Patients
Dedicated Neuro-Intensive Care Unit for Complex Stroke Patients Peer Review Process Participation in Clinical Stroke Research (IRB approved) Performance Measures The 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.

JC Core Measure for Primary Stroke Centers
DVT Prophylaxis by hospital day 2 Antithrombotics by hospital day 2 Discharged on Antithrombotics Anticoagulation for Patients with Atrial Fibrillation tPA given Discharged on Statin Stroke Education Plan for Rehabilitation

CSTK Draft Measures CSTK-01 NIHSS on Arrival
CSTK Modified Rankin Score (mRS) at 90 days CSTK Severity Measurement on Arrival SAH/ICH CSTK INR Reversal Achieved CSTK-04a Median Time to Treatment with a Procoagulant Reversal Agent CSTK-04b Median Time to INR Reversal CSTK Hemorrhagic Complication (Overall) CSTK-05a Hemorrhagic Complication for Patients treated with IV tPA without catheter based reperfusion CSTK-05b Hemorrhagic Complication for Patients treated with IA Thrombolytic Therapy or Mechanical Endovascular Procedure with or without IV tPA CSTK Nimodipine Treatment Initiated CSTK Median Time to Recanalization Therapy CSTK-7a Thrombolysis in Cerebral Infarction (TICI) Post Treatment Reperfusion Grade Being piloted now

Stroke & Neurovascular Center
SNC Stroke & Neurovascular Center New Jersey NJ 2012: 1st CSC NorthEast - JC 2011: 2nd Biplanar Angiography Suite Architect of NJ’s Stroke Designation Law 1996: NJ’s 1st Biplanar Angiography Suite 2013: Stroke Dedicated Critical Care Transport 2011: Initiated NCCU 1995: NJ 1st Stroke Unit 2007: NJ-Designated Comprehensive Stroke Center 1996: NJ’s 1st IV tPA use in stroke 2014: Stroke Bays in ED with a built in CT In 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 Unit 1956: 1st Case of angiographic Fibrinolytic administration in US for stroke treatment

Thank You!

Standards

Standard PR: Program Management
PR1: The program defines its leadership roles.

Medical Executive Committee Primary Medical Doctors &
JFKMC STROKE CENTER ORGANIZATION Executive VP & System COO Executive VP & COO JFK Medical Executive Committee Chairman of NSI Director Stroke & Neurovascular Center Chief Medical Officer Vascular Neurologists Neurointerventionalists Neurointensivists Neurosurgery Neuroradiology NCCU/ Neurointervention Director Stroke Center Director Primary Medical Doctors & Private Neurologists Emergency Department Director Rehabilitation Director 1.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, Attendings Emergency Medical Services Clinical and Allied Health Services (PT/OT/Speech) (Dietary/Lab) Director Patient Care Services QI Coordinator Stroke Coordinator Stroke APN Director Of Social Work and Case Management Stroke Registrar Clinical Trials Coordinators Nursing

Private Neurology Staff
Standard PR.2: The program is designed, implemented, and evaluated collaboratively. Multidisciplinary Stroke Committee PATIENT EMS ED Core Stroke Committee Private Neurology Staff Nursing Radiology Laboratory Case management Social work Rehabilitation Pharmacy QI Coordinator designs tools for implementation and measurement approves CPGs This 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 measures assesses compliance with CPGs

Neuro-Intervention/NCCU
Standard PR.2: The program is designed, implemented, and evaluated collaboratively. JFK Medical Center Squad Council PATIENT EMS ED Core Stroke Committee Neuro-Intervention/NCCU EMS/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.

Standards: The Program….
PR3- meets the needs of the target population and/or health care service area Needs survey, program mission PR4- follows a code of ethics PR5- complies with applicable laws and regulations PR6- has current reference and resource materials readily available Clinical Practice Guidelines-hospital intranet Standard written order sets- patient care areas PR7- 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.

Clinical Practice Guidelines
Emergency Management of Acute Ischemic Stroke Inpatient Treatment of Stroke Management of Hemorrhagic Stroke Transient Ischemic Attack with Observational Services Management of Aneurysmal Subarachnoid Hemorrhage Endovascular Procedures Guidelines

PR8- The Program communicates to participants the scope and level of care, treatment, and services it provides. Advanced Imaging Capabilities Procedures: Aneurysms: Microsurgical Neurovascular Clipping/ Neuroendovascular Coiling Extracranial Carotid Artery Stenting/ Endarterectomy Staff Availability (24/7) Physicians 2 Endovascular Neurologists Interventional Radiologists ● Neuroradiologists Vascular Neurologists ● Vascular Neurosurgeons Neuro-Intensivists & Medical Intensivists Surgeons with expertise in carotid endarterectomy Imaging Staff Available 24/7 Certified Radiology Technicians, MRI Technologists, Endovascular Nurses & Technicians On call schedule available;

Staff Availability Rehabilitation Staff Advanced Practice Nurse
Director: Expertise & experience in neuro-rehabilitation Director of Inpatient Rehabilitation Director of JFK Rehabilitation Consult Service PT/OT- available 6 days, on call the 7th ST- available 7 days a week Advanced Practice Nurse Support delivery of evidence based acute stroke assessment and management Expert nursing consultation and oversight Develop and deliver acute stroke continuing education programs Participate in PI processes and CSC research The rehab services are directed by physician with expertise & experience in neuro-rehb PT/OT available 6 days, on call the 7th to perform pt assessment during the acute stroke phase ST available 7 days a week to perform swallowing function assessments

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 managed Code Stroke Process 24/7 availability of neurological assessment for IV tPA PR10- Eligible patients have access to the program The 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.

Standard DF: Delivering/Facilitating Clinical Care
DF1: Practitioners are qualified and competent DF2: 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 requirements DF3: 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 Protocols All 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 Stroke DF2 Patient assessed to identify post hospital care requirements (AR, SAR, SNIF etc) & family members/caregivers assessed to determine readiness to provide pt care

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 booklet Stroke Care Discharge Instruction Sheet SE.3: The program addresses participants’ education needs. Post hospital care, durable medical equipment, respite care CSC sponsors at least 2 public educational activities that focus on stroke prevention annually Informed 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.

Standard CT: Clinical Information Management
CT.1: Participant information is confidential and secured. CT.2: Information management processes meet the program’s internal and external information needs. Stroke Team response times CT.3: Participant information is gathered from a variety of sources. CT.4: The program shares information with any relevant practitioner or setting about the participant’s disease or condition across the continuum of care. CT.5: The program initiates, maintains, and makes accessible a health or medical record for every participant. CT1: privacy policy management of medical records CT3: ED triage & nursing (re)-assessment, MD H&P CT4: sharing info b/n healthcare workers

Standard PM: Performance Measurement
PM1: The program has an organized, comprehensive approach to performance improvement. Peer Review Process Collection of data: Periprocedure complication rates for: Placement of transducer & ventriculostomy Performance of decompressive craniectomy & endovascular recanalization Volume requirements Follow up phone calls CSC publicly reports outcomes related to interventional procedures Pm1: 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.

Performance improvement
QI Coordinator Stroke Nurse Coordinator Core Stroke Committee Along with QI, The Stroke Nurse Coordinator also tracks all of these measures for compliance. tracking compliance with required stroke measures Concurrent tracking of compliance with orders, smoking cessation, patient stroke education, stroke measures Concurrent tracking of code stroke process Concurrent tracking of stroke order sheet use

Stroke Measures JC 8 Core Stroke Measures Dysphagia Screening
Smoking Cessation Code Stroke Response Times Code Stroke called Door to MD contact Door to CT done CT done to read Labs & EKG ordered to read Door to Drug In Hospital complications UTI, DVT, and pneumonia Stroke Measures Time to assemble team: add in as PI measure if we get from J

PM2: The program uses measurement data to evaluate processes and outcomes. Stroke registry Analysis of measurement data Complication rates for CEA & CAS (<6%) Diagnostic catheter angiography Periprocedure 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.

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.

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